Ala A. Abdel Jalil

An obscure cause of gastrointestinal bleeding: Renal cell carcinoma metastasis to the small bowel

Highlights • Renal cell carcinoma metastases to the gastrointestinal tract (excluding the liver) accounts for about (0.2 − 0.7)% of RCC.• RCC metastases to the gastrointestinal tract may occur years after resection of RCC.• The tyrosine kinase inhibitor Sunitinib has also been shown to have survival benefits for patients with RCC metastasis.• Vascular-endothelial growth factor receptor (VEGFR) as well as the mTOR-signaling pathway have been used as a treatment for RCC metastasis with good results.• Use of VCE and push enteroscopy are of beneficial value in the diagnosis of obscure GI bleeding.

Physicians' attitude toward organ donation and transplantation in the USA.

The public views organ donation favorably, with 60–90% of survey responders expressing a willingness to be an organ donor (1, 2). However, this positive attitude translates to nationwide donation rate of less than 40% (3). There is a paucity of literature addressing organ donation from a provider viewpoint. We conducted a survey to find out the percentage of physicians who were registered organ donors and the attitude of physicians in the USA toward a one possible non-monetary incentivized system to increase organ donation pool. A multidisciplinary panel of gastroenterology fellows and transplant hepatologists developed a 19-question electronic survey. Content validation and survey methodology were completed utilizing literature review, item generation, and small and large group discussions. The survey questions were piloted with a focus group of 15 physicians at three different institutions for face and content validity, feasibility and to ensure that all content domains were covered. This included evaluation on relevance and readability of each item, revision of existing items, and additions to the survey as needed. An electronic invitation to participate in the electronic survey was sent to 4000 residency and fellowship program directors in the USA. The anonymous survey was run through Google Documents© and included questions characterizing demographics, awareness of organ shortage, respondent organ donation status, and attitude toward assigning a higher priority to organ donors should they require liver transplantation in the future and reasons for opting against organ donation. The survey (Supplement 1) can be accessed through the following website https://docs.google. com/spreadsheet/viewform?formkey=dC1PMGtq Vk00d0JuWWhlWENMTmszZkE6MA. A total of 724 physicians in different specialties and subspecialties representing a broad sample of trainees and attending physicians at institutions across the nation participated. Eighteen physicians were excluded due to missing donor status. Around 86% of responders were aware about organ shortage problem and its consequences. The estimated number of participating physicians in the USA is around 878,194 physicians (4). Thus, the calculated confidence interval is 3.65% (95% confidence level). Chi-square and Student’s t-test were used to examine differences between those respondents registered as donors (n = 539 physicians, 76.3%) and those who were registered as non-donors (n = 167 physicians, 23.7%). Table 1 summarizes the demographics and characteristics of the participants as well as attitude toward assigning a higher priority to organ donors should they require liver transplantation in the future. There were no differences between the two groups with regard to age, gender, specialty, level of training, location of practice, and involvement in the care of liver transplant recipients having liver disease or having a close relative or friend with liver disease. Respondents who were identified as donors were more significantly aware about issues related to organ shortage and its consequences (87.8% vs. 80.1%, p < 0.03). The most common reasons for declining to register as organ donor included the following: religious purposes, followed by concerns about resultant poor medical care should a donor require medical care, rejecting the idea of surgical intervention following death as well as beliefs that the current organ allocation system is unfair. Among industrial countries, Israel’s organ donation has been one of the lowest. This led to introduce a new measurements including The Organ Transplantation Law in 2008. One component of the law included granting prioritization in organ allocation to those who registered as organ donors. As a consequence, the number of new registered donor has increased. Furthermore, there was a significant increase in the number of deceased organ donors. The organ donation rate

Manometric Subtypes of Ineffective Esophageal Motility

OBJECTIVES: Ineffective esophageal motility (IEM) is characterized by well‐defined manometric criteria. However, much variation exists within the diagnosis: Some patients exhibit exactly the required five weak swallows to make the diagnosis. Others show consistently ineffective swallows with total absence of any normal swallow. “We hypothesize” there are two different manometric subtypes of IEM; IEM Alternans (IEM‐A) and IEM Persistens (IEM‐P). METHODS: A total of 231 IEM patients were identified by high‐resolution manometry (HRM). IEM defined by distal contractile integral (DCI) <450 mm Hg/s/cm in ≥50% of test swallows. Abnormal reflux study was defined by excess total number of reflux episodes, abnormal esophageal acid exposure, or positive symptom association. RESULTS: A total of 195 (84%) patients had IEM‐A and 36 (16%) had IEM‐P. A striking gender difference with 34% of IEM‐A being males compared to 53% of IEM‐P. (P=0.03). Mean age of IEM‐P (59.6 years+/−13.1) was greater than IEM‐A (55.5 years+/−13.6) (P=0.04). Mean lower esophageal sphincter (LES) resting pressure was significantly lower in IEM‐P (20.8 mm Hg+/−1.4) than IEM‐A (29 mm Hg+/−1.2) (P=0.002). There was no difference in LES‐integrated relaxation pressure (IRP), bolus transit, or manometric presence of hiatal hernia between the two groups. Out of 146, 89 (61%) patients had abnormal reflux study. Esophageal acid exposure in upright position was significantly higher in IEM‐P than IEM‐A (3.5 vs. 1.7%, P=0.04). Poor gastric acid control on proton pump inhibitor (PPI) was more prevalent among IEM‐P patients (58%) than IEM‐A (27%) (P=0.007). In subgroup analysis of 41 IEM patients with dysphagia, DCI for liquid swallows was significantly lower in IEM‐P (111+/−142 mm Hg/s/cm) compared to IEM‐A (421+/−502 mm Hg/s/cm) (P=0.04), lower mean LES resting pressure in IEM‐P (16.6+/−9 mm Hg) than IEM‐A (31.7+/−18 mm Hg) (P=0.01). CONCLUSIONS: There are two distinct manometric IEM subtypes; IEM‐P with an older male predominance, more advanced reflux disease, weaker LES, and worse response to PPI; likely a more advanced manifestation than IEM‐A. However, the question if there are different etiologies underlying the two subtypes remains to be answered.

ERCP and fluoroscopy time.

To the Editor: We read with interest the study of Romagnuolo and Cotton (1). The study reported different factors that predict prolonged fluoroscopy time (FT) during endoscopic retrograde cholangiopancreatography (ERCP) (1). In our multicenter study (n=414, ERCP procedure performed by six endoscopists in three American centers) that was partially published as an abstract and presented as poster in ACG meeting 2013, the strongest predictive factor of prolonged FT utilization during ERCP procedure was the anatomical location of the pathology being treated (intrahepatic vs. pancreatic vs. extrahepatic) with mean FT 4.96 min for extrahepatic cases, 6.75 min for pancreatic cases, and 12.9 min for intrahepatic cases (P<0.05) (2). It would be interesting if the authors can extract the relationship between FT and anatomical location of the pathology from the ERCP Quality Network.

Primary papillary thyroid carcinoma diagnosed by using endoscopic ultrasound with fine needle aspiration.

There is paucity in the literature on the use of endoscopic ultrasound (EUS) for evaluating the thyroid gland. We report the first case of primary papillary thyroid cancer diagnosed by using EUS and fine needle aspiration (FNA). A 66-year-old man underwent EUS for the evaluation of mediastinal lymphadenopathy. FNA of the lymph nodes showed benign findings. A hypoechoic mass was noted in the right lobe of the thyroid gland. Therefore, FNA was performed. The cytological results were consistent with primary papillary thyroid cancer.

Removal of Esophageal Variceal Bands to Salvage Complete Esophageal Obstruction

Esophageal varices develop in almost half of the patients with cirrhosis, and variceal hemorrhage constitutes an ominous sign with an increased risk of mortality. Variceal banding is considered an effective and mostly safe measure for primary and secondary prophylaxis. Although adverse events related to banding including dysphagia, stricture formation, bleeding, and ligation-induced ulcers have been described, complete esophageal obstruction is rare, with only 10 reported cases in the literature. Among those cases, 6 were managed conservatively; 1 patient had esophageal intraluminal dissection from an attempt to remove the bands using biopsy forceps but ultimately recovered with conservative management. Three patients developed strictures following removal of the bands, requiring repeated sessions of dilation therapy. We report on a patient who developed absolute dysphagia and complete esophageal obstruction after variceal banding. We successfully used the endoloop cutter hook to release the bands intact and restore luminal integrity.