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**Abstract:**



A Retrospective Cohort Study: Utility of Fecal Occult Blood Test in the Acute Hospital Setting and Its Clinical Impacts

Background
Small Intestinal Hemangiomas are a rare vascular finding which, left undiagnosed, may present as uncontrolled bleeding or perforation. Though the emergence of new gastrointestinal imaging technologies, including capsule endoscopy and balloon-assisted enteroscopy, has improved preoperative diagnosis significantly, the pre-treatment rate remains less than 30%. Given this low pre-treatment rate of small bowel hemangiomas, we must better prepare physicians to identify and manage patients with hemangiomas of the small intestine.

Case Presentation
A 25-year-old male presented with a six-year history of epigastric abdominal pain and microcytic anemia without overt gastrointestinal hemorrhage. CT Abdomen and Pelvis demonstrated several filling defects throughout the ileum. EGD demonstrated a friable vascular mass without bleeding in the duodenal bulb, with biopsy suggestive of hemangioma. Endoscopic ultrasound demonstrated a 15mm lesion in the deep mucosa. Upper GI series with small bowel follow-through showed multiple luminal filling defects in the distal jejunum and ileum. Further endoscopy and surgical resection were deferred due to high risk of bleeding. The patient was started on a bowel regimen and is undergoing expectant management.

Discussion
Though small bowel hemangiomas are currently estimated to comprise less than 0.05% of gastrointestinal neoplasms, the spread of capsule endoscopy and double balloon enteroscopy suggests an imminent rise in the diagnosis of asymptomatic hemangiomas. In patients presenting without overt gastrointestinal bleeding, abdominal pain, and microcytic anemia, small bowel imaging is an important adjunctive diagnostic technique to endoscopy. Given the low pretreatment rate of small bowel hemangiomas, we must better prepare physicians to identify and manage patients with hemangiomas of the small intestine.

Multiple Hemangiomas of the Small Intestine: A Rare, Underdiagnosed Cause of Chronic Gastrointestinal Bleeding

Association Between Mucosa-Associated Lymphoid Tissue (MALT) Surgery and Inflammatory Bowel Disease (IBD): A Systematic Review

Background: Intraductal Papillary Mucinous Neoplasms (IPMNs) are the most common subset of cystic neoplasms and are currently only managed by surgery and surveillance; however, because pancreatic surgery proves to be an unnecessary risk in benign cases, an alternative treatment plan is crucial. Previous experimentation showed that IPMNs exhibited higher levels of MAP kinase, a signaling cascade that regulates cell proliferation and differentiation, than pancreatic ductal adenocarcinoma (PDAC). We hypothesized that IPMNs would be more susceptible to MEK (upstream regulator in the MAP kinase pathway) inhibition than conventional PDAC cells due to the significant increase of MAPK phosphorylation in IPMNs.

Methods: 4619 cells were obtained from a mouse PDAC tumor carrying mutations in Kras and Trp53; 4838 cells were obtained from a mouse IPMN tumor carrying mutations in Kras and Gnas (doxycycline-inducible). Cells were treated with 1 ug/ml doxycycline for 24hr prior to treatment. Gene expression was determined by RT-qPCR at 24hr of 100nM Trametinib or vehicle (DMSO) normalizing to Pmm1 levels. Western blotting for phospho-ERK 1/2, total ERK1/2, and GAPDH was used to control for trametinib efficiency. Growth was determined by MT Viability Assay, following indicated concentrations of Trametinib at the indicated timepoints.

Results: Trametinib significantly inhibited expression of Aqp5 in both PDAC and IPMN cells. Mki67 fold change showed a significant decrease in both lines with Trametinib whereas Pcna fold change was significant between PDAC Trametinib vs. vehicle but not in the IPMN line. No significance was noted for Gnas, Spdef, Cdkn2a, and Cdkn1a. Growth and proliferation curves showed the highest concentration of Trametinib (100 nM) prohibiting growth the most in both cell lines.

Conclusion: MEK inhibition had similar effects on PDAC and IPMN cells. Trametinib decreased expression of proliferation markers similarly in both cell lines, consistent with a similar inhibition of growth. Expression of growth arrest markers was unaffected by trametinib. The role of MEK in regulating Aqp5 is novel and will be pursued in future experiments. These experiments were performed in 10% fetal bovine serum which is highly growth stimulatory. Future experiments could treat cells in low or no serum to determine if Trametinib has more of an effect under nutrient-limited conditions. Overall, IPMNs need to be studied more regarding their differences from PDAC and the MAP Kinase pathway.

Role of MAP Kinase in IPMN and PDAC

Background
SLC6A4 (SERT) is downregulated in IBD patients and pre-clinical models of IBD. Despite the established roles of serotonin (5-HT) and SERT in maintaining the gut and its microbiome, the mechanisms by which decreased SERT contributes to intestinal inflammation remain unclear.

Methods
SERT KO and WT mice administered Dextran sulfate sodium (DSS) induced chronic colitis underwent fecal and serum metabolomic analysis. Bioinformatic analysis identified enriched metabolic pathways and microbial-related metabolites. Disease severity was evaluated with myeloperoxidase (MPO) activity, RT-PCR, immunoblotting, immunohistochemistry. Tight junction perturbation was assessed by immunofluorescence, Western blotting, RT-PCR and serum endotoxin levels. We computed Spearman correlation coefficients between the abundance of the altered microbial metabolites and disease activity.

Results
SERT knockout (SERT KO) mice induced with chronic colitis revealed increased disease severity. The baseline metabolomic profiles of SERT KO mice resembled those of WT mice with chronic colitis, suggesting a predisposition to metabolic dysregulation. Metabolomic analysis demonstrated distinct profiles in feces and serum associated with chronic colitis in mice mimicking human IBD such as variations in purine and plasmalogen metabolites. SERT deficiency alone led to altered tryptophan metabolism, changes in oxidative metabolism, and dysregulation of phosphatidylcholines and plasmalogens in feces and serum. Mechanistically, SERT deficiency in an inflammatory context led to diminished ileal tight junction expression and increased serum endotoxin levels worsening disease. Furthermore, we identified several microbial metabolites in the feces and serum correlating with disease activity. 

Conclusion
SERT deficiency augmented chronic inflammation induced by DSS, perturbed intestinal barrier dysfunction, and caused microbially influenced metabolic alterations which corresponded to disease activity. The results of this study highlight novel changes in both host-derived and bacteria-derived serum metabolites and fecal metabolites occurring due to the loss of SERT. These findings demonstrate the functionally disruptive role of SERT in metabolic pathways associated with IBD and suggest potential therapeutic targets for intestinal inflammation.


Serotonin transporter deficiency-driven metabolomic derangements drive intestinal inflammation

Eosinophilic gastroenteritis is an underdiagnosed condition that presents with long term complications in patients with vague gastrointestinal symptoms. The case of a 72-year-old man highlights the common symptoms of eosinophilic gastroenteritis (abdominal pain, dysphagia, diarrhea) and how severe complications can arise such as cholecystitis prompting surgery. We illustrate the importance of identifying features of eosinophilic gastroenteritis and limiting misdiagnosis, such as IBS. This allows access to appropriate treatment before severe complication arise. Family physicians play and key role in diagnosis and management of this condition. Our patient spent 3 weeks on the inpatient service, went through many imaging and laboratory tests, and eventually underwent a prompt cholecystectomy for a gallbladder perforation secondary to acute necrotizing cholecystitis. Likely, if diagnosed earlier, this patient may have been able to avoid this complication that led to surgery by receiving proper treatment. The case review highlights the clinical features, pathophysiology, diagnostic criteria, and current guidelines for treatment of eosinophilic gastroenteritis.

A Rare Case of Eosinophilic Gastroenteritis Complicated by Necrotizing Cholecystitis

There is a role for the gut virome in numerous dysbiosis-associated states including obesity, inflammatory bowel diseases, and C. difficile infection. These findings are likely related to the ecological function of bacteriophages (phages) in regulating the structure, composition, and diversity of the gut microbiome. Dysregulation in the gut phage community may therefore lead to microbiome dysbiosis. To study whether exogenous phage administration may have therapeutic potential as a treatment for dysbiosis, our lab purified phages from lactic acid bacteria-fermented sauerkraut to test the effect of sauerkraut phages in a mouse model for stress-induced dysbiosis. Stress is strongly associated with dysbiosis, decreased microbiome diversity, and the growth of pro-inflammatory bacteria in the gut microbiome. Sauerkraut and other fermented foods have been shown to promote microbiome diversity and our lab hypothesized that phages may have a role in mediating this effect.

Bacteriophages derived from fermented food increase cecal microbiome diversity in the setting of stress-induced dysbiosis

Introduction
Colon cancer is one of the top five leading causes of cancer in both males and females. There is a well-known association between colon cancer and microbial infections. The presence of certain bacterial infections in the appropriate clinical context should prompt further investigation of colon cancer.

Case Presentation
A 41-year-old male with history of alcohol use disorder and bipolar disorder who presented for acute encephalopathy after cardiac arrest with return of spontaneous circulation within 2 minutes in the field.
In the emergency department he was found to be hypotensive and hypoxic; labs revealed leukocytosis (50.9 K/ul) with bandemia (15%), anemia (5.9g/dl), and LFTs consistent with acute liver failure. CT abdomen/pelvis showed hepatosplenomegaly, pelvic ascites, colonic wall thickening and luminal narrowing in mid-sigmoid colon.
He was admitted to the ICU for twelve days for septic shock intermittently requiring vasopressors, acute liver failure, and respiratory failure. A diagnostic paracentesis revealed a transudative effusion; blood cultures were positive for Clostridium septicum and Enterococcus avium.
A subsequent colonoscopy demonstrated a sigmoid colonic mass whose pathology was consistent with adenocarcinoma. Due to his acute decompensated liver failure secondary to alcohol use; he was not a candidate for surgery. The family placed the patient in hospice care and he eventually expired.

Discussion
Colon malignancy has been associated to certain bacterial strains, with the most common being Streptococcus bovis/gallolyticus, and less frequently Clostridium septicum, Enterococci species, Bacteroides fragilis, Fusobacterium nucleatum, and other Streptococci species. In fact, of the approximately 106,180 new cases of colon cancer reported yearly, 10-25% are associated with infections caused by Streptococcus bovis and Clostridium septicum.
Clostridium septicum is an opportunistic, gram-positive anaerobe that has several virulence factors, including alpha toxin. It can survive in acidic environments due to its ability to produce spores and has the capability to perforate the colonic epithelial lining, releasing spores into the blood and leading to bacteremia. The risk factors for C. septicum infection include immunosuppressed states, hematological malignancies, neutropenia, and diabetes mellitus. Unfortunately, C. septicum infection has a high mortality rate of 60%, which can only be diagnosed through positive cultures.
Treatment for C. Septicum infection varies depending on the presentation, as it can cause aortitis, myonecrosis, gangrene, cellulitis, septic shock, fasciitis, hemolysis, and abscess. However, early antibiotics and possible surgical intervention are recommended for effective management. Piperacillin/tazobactam or penicillin G are the first-line treatments for C. septicum infection. Therefore, it is crucial to identify and manage this infection as early as possible to prevent the high mortality rate associated with it.
Conclusion
Clostridium septicum infection and colonic malignancy is a well-known association therefore clinicians should have a high suspicion for colon cancer in patients who present with this infection.

A Potentially Lethal Harbinger: Clostridium Septicum Bacteremia in a Patient Found to have Adenocarcinoma of the Colon

Background:
Gastric cancer is among the top five cancer-burden in the United States and worldwide. The aim of our study is to investigate the racial variations in gastric carcinoma among individuals aged 50 years and above.

Methods:
We conducted a retrospective study using the SEER database, 17 registries, Nov 2021 Sub (2000- 2019) to identify individuals diagnosed with gastric cancer of 50 years and above age group. Age adjustment was done using the 2000 US population as a standard population. We collected racial/ethnic information related to incidence and incidence-based mortality of stomach cancer in our desired age groups.

Results:
This study included a total population of 109,352 patients of 50 years and above age with stomach cancer, out of which 71.6% were white, 12.9% were black, 14.2% were Asian or Pacific Islanders (API), and 0.9% were 1 American 1 Indian/ 1 Alaskan native (AI/AN). Based on incidence, all-cause mortality was 79.2% in white population, 78.9% in black, 71.5% in API and 82.8% in AI/AN. The incidence rate among white, black, API, and AI/AN were 20.6, 35, 36.3, and 21.3 per 100,000 population respectively, whereas the incidence-based mortality among the above races were 16.4, 28.9, 26.7, and 18.7 per 100,000 standard population. According to race, the incidence in white was 71.6% with incidence-based mortality of 79.2%. In Black incidence was 12.9% with incidence-based mortality of 78.9%. In American Indian incidence was 0.9% and incidence-based mortality was 82.8% and for Asian
incidence was 14.2% and incidence-based mortality of 71.5%.

Conclusion:
Our study outlines the racial disparities in the incidence and mortality of gastric carcinoma among individuals with gastric carcinoma among individuals aged 50 years and above. Although, gastric carcinoma is diagnosed mostly in the white population followed by Asian or Pacific islanders, black and then American Indians. The incidence rate and incidence-based mortality rates were highest among
Asian/Pacific Islanders and Black compared to that of white and American Indian/Alaskan natives. These findings help to address the disparities through interventions and healthcare policies targeted to improve gastric cancer incidence and outcomes across a diverse racial or ethnic population in the United
States. Further research is warranted to explore the underlying factors contributing to the racial disparities in gastric cancer.

Racial Disparities in Incidence and Mortality of Gastric Carcinoma of Individuals
Aged 50 Years and Above: A Population-Based Analysis

The association between viral illness, inflammation, and organ dysfunction and damage is well-established throughout the literature. The interaction between angiotensin-converting enzyme 2 (ACE2) receptors and SARS-CoV-2 has been associated with the pathogenesis of SARS-CoV-2-related illness. COVID-19 can result in gastrointestinal complications due to direct or indirect insult (cytokine storm). Diarrhea is a common gastrointestinal manifestation of pancreatic insufficiency, inflammatory bowel disease, and SARS-CoV-2 infection. In COVID-19 patients, it’s the most common GI manifestation. We describe a unique case of COVID-19-induced concurrent exocrine Pancreatic Insufficiency and Inflammatory Bowel Disease that presented as chronic diarrhea. Given that the long-term effects of COVID-19 remain unknown, this case underscores the importance of systematically documenting COVID-19 manifestations to establish a temporal pattern of post-infection pathology for future research.

Long COVID: A Case of Concomitant Pancreatic Insufficiency with Inflammatory Bowel Disease

Background
Crohn’s disease (CD) and ulcerative colitis (UC) are inflammatory disorders of the GI tract that may cause symptoms leading to the alteration of dietary intake to control symptoms. There are recommended diets for treatment of inflammatory bowel disease (IBD), but many diets have low-quality evidence for efficacy. However, in an effort to relieve symptoms, patients or families may self-restrict certain foods, leading to the development of restrictive eating behaviors.
In 2013, avoidant-restrictive food intake disorder (ARFID) was added to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) to identify patients who actively restrict food intake leading to insufficient caloric/nutritional intake and causing at least one of the following complications: weight loss, nutritional deficiency, dependence on nutritional supplements, or psychosocial impairment. 
As ARFID is a relatively new diagnosis, the prevalence of this diagnosis in chronic disease states has not been well-characterized. A recent adult study measured the prevalence of ARFID in an adult IBD population, examined nutritional risk in the context of ARFID risk, and identified risk factors for ARFID in IBD patients. 28/161 (17%) patients had a positive ARFID risk score, as measured by the Nine-item ARFID Screening tool (NIAS).
Currently, there are no studies evaluating the prevalence of ARFID in pediatric patients with IBD. We estimate that the prevalence is high based on anecdotal food avoidances, particularly during a flare of symptoms. We also hypothesize that patients who have high ARFID risk scores may be more at risk for nutrition deficiencies. 
Methods
This is a prospective, observational cohort study of pediatric patients (age 0-17) with inflammatory bowel disease. Fifty patients will be enrolled. Participants complete surveys about eating behaviors and nutritional status after scheduled clinic visits. Study outcomes measured are ARFID risk score (calculated by the NIAS) and nutritional status (height and weight velocity z-scores, mid-upper arm circumference z-scores). 
Results
Based on recent guidelines, a positive ARFID risk score is defined as a score that meets at least one of the following criteria: ≥10 in the picky eating sub-score, ≥9 in the appetite sub-score, ≥10 in the fear sub-score, ≥24 in the total NIAS score Preliminary results suggest a prevalence of ARFID in participants based off a positive ARFID screen to be 21% (8/38 patients), compared to the estimated prevalence of ARFID in community pediatric populations of 2%.
Conclusion
We anticipate that the results of this study can help clinicians address nutritional deficiencies in pediatric IBD patients before it becomes detrimental to patients’ well-being. With the knowledge that pediatric IBD patients are more at risk of ARFID, their needs can be predicted by clinicians and dietitians to ensure proper care of patients.

Evaluating the Prevalence of Avoidant Restrictive Food Intake Disorder in Pediatric Patients with Inflammatory Bowel Disease

There is very sparse data about prevalence
and outcome of gastric intestinal
metaplasia (GIM) in children. Our aim is to
review clinical and endoscopic findings in
children with GIM diagnosed by gastric
biopsy (bx) undergoing
esophagogastroduodenoscopy (EGD) for
various indications at our institution; also
review and compare above findings in
patients with repeat EGD in patients with
GIM.

Underline digital video library

A Retrospective Cohort Study: Utility of Fecal Occult Blood Test in the Acute Hospital Setting and Its Clinical Impacts

Multiple Hemangiomas of the Small Intestine: A Rare, Underdiagnosed Cause of Chronic Gastrointestinal Bleeding

Association Between Mucosa-Associated Lymphoid Tissue (MALT) Surgery and Inflammatory Bowel Disease (IBD): A Systematic Review

Role of MAP Kinase in IPMN and PDAC

Serotonin transporter deficiency-driven metabolomic derangements drive intestinal inflammation

A Rare Case of Eosinophilic Gastroenteritis Complicated by Necrotizing Cholecystitis

Bacteriophages derived from fermented food increase cecal microbiome diversity in the setting of stress-induced dysbiosis

A Potentially Lethal Harbinger: Clostridium Septicum Bacteremia in a Patient Found to have Adenocarcinoma of the Colon

Racial Disparities in Incidence and Mortality of Gastric Carcinoma of Individuals Aged 50 Years and Above: A Population-Based Analysis

Long COVID: A Case of Concomitant Pancreatic Insufficiency with Inflammatory Bowel Disease

Evaluating the Prevalence of Avoidant Restrictive Food Intake Disorder in Pediatric Patients with Inflammatory Bowel Disease

Gastric Intestinal Metaplasia (GIM) in Children-How Common It Is And What Happens to It-A Pilot Project

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