Dig Dis Sci Research Articles

Letters to the editor

Dental UpdateVol. 50, No. 6 LettersLetters to the editorNg Yue Myng, Lim Zhi Yin Joan, Phrabhakaran NambiarNg Yue MyngDepartment of Restorative Dentistry, Faculty of Dentistry, MAHSA University, Selangor, MalaysiaSearch for more papers by this author, Lim Zhi Yin JoanDepartment of Restorative Dentistry, Faculty of Dentistry, MAHSA University, Selangor, MalaysiaSearch for more papers by this author, Phrabhakaran NambiarDepartment of Oral Biology and Biomedical Sciences, Faculty of Dentistry, MAHSA University, Selangor, Malaysia; Department of Oral and Maxillofacial Clinical Sciences, Faculty of Dentistry, University of Malaya, Kuala Lumpur, MalaysiaSearch for more papers by this authorNg Yue Myng; Lim Zhi Yin Joan; Phrabhakaran NambiarPublished Online:13 Jun 2023https://doi.org/10.12968/denu.2023.50.6.536aAboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail View article References Greenwood M, Meechan JG. General medicine and surgery for dental practitioners: part 2. Medical emergencies in dental practice: the drug box, equipment and basic principles of management. Br Dent J 2014; 216: 633–667. https://doi.org/10.1038/sj.bdj.2014.447 Medline, Google ScholarQuigley EM, Locke GR, Mueller-Lissner S et al.. Prevalence and management of abdominal cramping and pain: a multinational survey. Aliment Pharmacol Ther 2006; 24: 411–419. https://doi.org/10.1111/j.1365-2036.2006.02989.x Medline, Google ScholarOladosu FA, Tu FF, Farhan S et al.. Abdominal skeletal muscle activity precedes spontaneous menstrual cramping pain in primary dysmenorrhea. Am J Obstet Gynecol 2018; 219: 91.e1–91.e7. https://doi.org/10.1016/j.ajog.2018.04.050 Medline, Google ScholarSandler RS, Stewart WF, Liberman JN et al.. Abdominal pain, bloating, and diarrhea in the United States: prevalence and impact. Dig Dis Sci 2000; 45: 1166–1171. https://doi.org/10.1023/a:1005554103531 Medline, Google ScholarBommelaer G, Poynard T, Le Pen C et al.. Prevalence of irritable bowel syndrome (IBS) and variability of diagnostic criteria. Gastroenterol Clin Biol 2004; 28: 554–561. https://doi.org/10.1016/s0399-8320(04)95011-7 Medline, Google Scholar FiguresReferencesRelatedDetails 2 June 2023Volume 50Issue 6ISSN (print): 0305-5000ISSN (online): 2515-589X Metrics History Published online 13 June 2023 Published in print 2 June 2023 Information© MA Dentistry Media LimitedPDF download

Long-term disease course, cost and prognosis of inflammatory bowel disease: epidemiological studies of a European and a Danish inception cohort.

Long-term disease course, cost and prognosis of inflammatory bowel disease: epidemiological studies of a European and a Danish inception cohort.

Editorial Comment.

No AccessJournal of UrologyAdult Urology19 May 2023Editorial CommentThis article comments on the following:Characterization of Gender Differences in H-index Within Urological Subspecialties Anna-Lisa V. Nguyen, David-Dan Nguyen, Ashley Cox, and Naeem Bhojani Anna-Lisa V. NguyenAnna-Lisa V. Nguyen Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada More articles by this author , David-Dan NguyenDavid-Dan Nguyen Division of Urology, University of Toronto, Toronto, Ontario, Canada More articles by this author , Ashley CoxAshley Cox Department of Urology, Dalhousie University, Halifax, Nova Scotia, Canada More articles by this author , and Naeem BhojaniNaeem Bhojani Division of Urology, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003537.01AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareFacebookLinked InTwitterEmail "Editorial Comment." The Journal of Urology, Publish Ahead of Print, pp. REFERENCES 1. Gender differences in promotions and scholarly productivity in academic urology. Can J Urol. 2017; 24(5):9011-9016. Medline, Google Scholar 2. Characterization of gender differences in h-index within urological subspecialties. J Urol. 2023; 210(2):000. Google Scholar 3. . The h-index in medicine and science: does it favor h-im or h-er? Successes and hurdles for women faculty. Dig Dis Sci.2022; 67:388-389. Crossref, Medline, Google Scholar 4. . Women are underrepresented and receive differential outcomes at ASM journals: a six-year retrospective analysis. mBio. 2020; 11(6):e01680-e01620. Crossref, Medline, Google Scholar Submitted December 28, 2022; accepted May 1, 2023; published 000. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsRelated articlesJournal of Urology8 May 2023Characterization of Gender Differences in H-index Within Urological Subspecialties Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Anna-Lisa V. Nguyen Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada More articles by this author David-Dan Nguyen Division of Urology, University of Toronto, Toronto, Ontario, Canada More articles by this author Ashley Cox Department of Urology, Dalhousie University, Halifax, Nova Scotia, Canada More articles by this author Naeem Bhojani Division of Urology, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada More articles by this author Expand All Submitted December 28, 2022; accepted May 1, 2023; published 000. Advertisement PDF downloadLoading ...

WEO Newsletter.

WEO Newsletter.

S1087 Cost-Effectiveness of Endoscopic Stricturotomy versus Resection Surgery for Crohn’s Disease Strictures

Introduction: Strictures in Crohn's disease (CD) increase the likelihood of requiring surgery, which is costly and invasive. In the last two decades, endoscopic therapies including endoscopic balloon dilation (EBD) and endoscopic stricturotomy (ESt) have emerged as effective and less invasive therapies for CD strictures.1 ESt in particular is advantageous for longer, fibrotic strictures, or strictures adjacent to anatomic structures requiring precision, and has shown a high rate of surgery-free survival.2-4 We therefore assessed the cost-effectiveness of ESt as compared to surgical resection for CD strictures. Methods: A microsimulation state-transition model compared ESt to surgical resection for patients with primary or anastomotic CD strictures. Our primary outcome was quality-adjusted life years (QALYs) over ten years, and strategies were compared at a willingness to pay (WTP) of $100,000/QALY from a societal perspective. Costs (2022 $US) and ICERs were calculated. Deterministic 1-way and probabilistic analyses assessed model uncertainty. Results: The surgery strategy cost more than 2.5 times the endoscopic stricturotomy strategy, but resulted in nine higher QALYs per 100 persons (Table). Overall, surgery had an ICER of $308,787/QALY, making ESt more cost-effective. The median number of endoscopic stricturotomies was 4 in the ESt strategy and 0 in the surgery strategy; the median number of surgeries was 0 and 2 respectively. One-way sensitivity analyses showed that quality of life after ESt as compared to that after surgery, probabilities of requiring repeated interventions, and surgical mortality and cost were the most influential parameters in our model (Figure). Probabilistic sensitivity analyses favored ESt in 65.5% of iterations. Conclusion: Endoscopic stricturotomy is cost-effective for managing primary or anastomotic Crohn's disease strictures. Post-intervention quality of life and probabilities of requiring repeated interventions exert most influence on cost-effectiveness; the decision between ESt and surgery should be made considering patients' risk and quality of life preferences. 1. Lee KE et al. Dig Dis Sci. 2022 Mar 15.2. Lan N et al. Gastrointest Endosc. 2019 Aug;90:259-268.3. Zhang LJ et al. Gastroenterol Rep (Oxf). 2019 Oct;8:143-150. 4. Lan N et al. Inflamm Bowel Dis. 2018 Mar;24:897-907.Figure 1.: Tornado diagram showing main drivers (variables and sensitivity ranges) of the incremental cost-effectiveness ratio (ICER). †Multiplicative factor by which probability Tables are multiplied. Abbreviations: CD (Crohn's disease), ESt (Endoscopic stricturotomy), ICER (Incremental cost-effectiveness ratio), Max (Maximum), WTP (Willingness to pay) Table 1. - Base Case Cost-Effectiveness Analysis Results Cost ($) Incremental Cost ($) Effectiveness (QALY) Incremental Effectiveness (QALY) ICER ($/QALY) Endoscopic Stricturotomy 16,748 6.28 Resection Surgery 45,135 28,388 6.37 9 QALYs per 100 persons 308,787 Abbreviations: QALY (Quality-adjusted life year), ICER (Incremental cost-effectiveness ratio).

OCTREOTIDE-INDUCED ASYSTOLE IN A 70-YEAR-OLD WOMAN

OCTREOTIDE-INDUCED ASYSTOLE IN A 70-YEAR-OLD WOMAN

It's Not What You Take Up, It's What You Keep: How Discoveries from Diverse Disciplines Directed the Development of the FDG PET/CT Scan.

Although imaging glucose metabolism with positron emission tomography combined with X-ray CT (FDG-PET/CT) has become a standard diagnostic modality for the discovery and surveillance of malignant tumors and inflammatory processes, its origins extend back to more than a century of notable discoveries in the fields of inorganic and organic chemistry, nuclear physics, mathematics, biochemistry, solute transport physiology, metabolism, and imaging, accomplished by pioneering and driven investigators, of whom at least ten were recipients of the Nobel Prize. These tangled and diverse roots eventually coalesced into the FDG-PET/CT method, that through its many favorable characteristics inherent in the isotope used (18F), the accurate imaging derived from coincidence detection of positron annihilation radiation combined with computed tomography, and the metabolic trapping of 2-deoxy-2-[18F]fluoro-D-glucose (FDG) in tissues, provides safety, sensitivity, and specificity for tumor and inflammation detection. The authors hope that this article will increase the appreciation among its readers of the insight, creativity, persistence, and drive of the many investigators who made this technique possible. This article is followed by a review of the many applications of FDG-PET/CT to the gastrointestinal tract and hepatobiliary system (Mandelkern in Dig Dis Sci 2022).

Multicenter Randomized Controlled Trial of Surveillance Versus Endoscopic Therapy for Barrett’s Esophagus With Low-grade Dysplasia: The SURVENT Trial: Study Rationale, Methodology, Innovation, and Implications

Multicenter Randomized Controlled Trial of Surveillance Versus Endoscopic Therapy for Barrett’s Esophagus With Low-grade Dysplasia: The SURVENT Trial: Study Rationale, Methodology, Innovation, and Implications

Rate of Autoactivation Determines Pancreatitis Phenotype in Trypsinogen Mutant Mice

The digestive protease trypsin plays a central role in the onset and progression of pancreatitis. 1 Hegyi E. et al. Dig Dis Sci. 2017; 62: 1692-1701 Crossref PubMed Scopus (100) Google Scholar Ectopic conversion of the inactive precursor trypsinogen to active trypsin in the pancreas is an early event in disease development. Biochemically, trypsinogen is activated by limited proteolysis of its activation peptide, which can be cleaved by 3 different enzymes: enteropeptidase (enterokinase), trypsin (autoactivation), and cathepsin B (CTSB) (Figure 1A). Because enteropeptidase is not expressed in the pancreas, pathologic intrapancreatic trypsinogen activation can only occur through autoactivation or by CTSB-mediated activation. Inborn mutations of human cationic trypsinogen (encoded by the serine protease 1, PRSS1, gene) accelerate trypsinogen autoactivation and cause hereditary chronic pancreatitis (CP). 2 Mayerle J. et al. Gastroenterology. 2019; 156: 1951-1968 Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar In contrast, human genetic studies and functional analysis of trypsinogen mutants failed to substantiate a pathogenic role for CTSB-mediated trypsinogen activation in CP (references in Demcsák et al 3 Demcsák A. et al. Sci Rep. 2019; 9: 9188 Crossref PubMed Scopus (5) Google Scholar ).

Editors' Selections from Relevant Scientific Publications

Editors' Selections from Relevant Scientific Publications

Closing the gender gap: building a successful career and leadership in research as a female gastroenterologist

The pillars of academic promotion include clinical service, research, teaching, and public engagement. Although women are more likely than men to pursue a career in academia after a gastroenterology fellowship (40% of women vs 25% of men choose this path), gender disparity in research and academic leadership remains. For example, only one woman was appointed assistant professor in all gastroenterology and hepatology divisions of university hospital centres in France in 2017–18, whereas ten men were appointed full professors and seven were appointed associate professors in that same period. 1 Aubart FC Roeser A Costedoat-Chalumeau N Papo T Piette J-C Women in internal medicine academic positions in France. Eur J Intern Med. 2019; 64: e18-e29 Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar Only 20% of faculty and 25% of full professors in divisions of gastroenterology in the USA are women; this gender disparity has not diminished over the past 35 years and is similar across basic science and clinical departments. 2 Richter KP Clark L Wick JA et al. Women physicians and promotion in academic medicine. N Engl J Med. 2020; 383: 2148-2157 Crossref PubMed Scopus (103) Google Scholar Even though the representation of female physicians as first authors (42%) and senior (23%) authors of original research published in US gastroenterology journals has increased over the past two decades, the proportion of female senior authors increased at a slower rate than female first authors and was lower than expected based on the proportion of women in academia. 3 Long MT Leszczynski A Thompson KD Wasan SK Calderwood AH Female authorship in major academic gastroenterology journals: a look over 20 years. Gastrointest Endosc. 2015; 81: 1440-1447 Summary Full Text Full Text PDF PubMed Scopus (78) Google Scholar , 4 Bhatia S Eluri S Kim E Angle H Dellon E Shaheen N Trends in female authorship of high impact publications in gastroenterology journals, 1997–2017. Am J Gastroenterol. 2018; 113: S652-S653 Google Scholar Similarly, representation of female first authors in high-impact European journals has increased since 1994, but it has plateaued in recent years. 5 Filardo G da Graca B Sass DM Pollock BD Smith EB Martinez MA-M Trends and comparison of female first authorship in high impact medical journals: observational study (1994–2014). BMJ. 2016; 352: i847 Crossref PubMed Scopus (271) Google Scholar In addition, the proportion of invited women speakers at major national gastroenterological meetings remains low: for example, at the British Society of Gastroenterology meeting in 2014, only 26% of speakers were female; at United European Gastroenterology week 2019, only 28% of speakers were female; and at Digestive Disease Week 2019, only 33% of speakers were female. 6 Brooks AJ Taylor EJ Arthurs EA et al. Gender differences in leadership, workforce and scholarly presentation within a national society: a gastroenterology perspective. Frontline Gastroenterol. 2019; 10: 2-6 Crossref PubMed Scopus (2) Google Scholar , 7 Khan Z Rukhshan R Bhatt A et al. persistent speaker gender gap at the premier digestive disease event. Dig Dis Sci. 2022; 67: 390-396 Crossref PubMed Scopus (1) Google Scholar , 8 Nakov R Alboraie M Tiniakos D UEG Equality and Diversity Task ForceHow to identify, encourage, and support suitable candidates for leading roles in scientific societies: the UEG experience. United European Gastroenterol J. 2021; 9: 874-876 Crossref PubMed Scopus (2) Google Scholar How can female gastroenterologists effectively build a successful career in research and overcome these barriers to achieving leadership and academic advancement?

P161 Implementation of Outcome Measurement – Case Finnish IBD register

Abstract Background Inflammatory bowel diseases (IBD) are becoming increasingly common. In Finland, during 2020, in total of 54 000 patients were diagnosed with IBD, and over 2000 new diagnoses are made every year. The Finnish university hospitals in collaboration with BCB Medical Ltd have built disease-specific registers to support and monitor the quality and effectiveness of health care. The IBD register (IBDR) collects data on the effectiveness of IBD treatments and their follow-up, where e.g. disease severity, treatment and outcomes are profoundly monitored. As combination, IBDR, MyHealth service, and IBD Symptom Diary enables patients’ health, functional status, experience and QoL monitoring to reach the health care goals. The service supports patient treatment pathway and makes designing more personalized treatments for IBD possible. Methods The IBDR is a web-based system integrated with electronic health record (EHR) systems, through which patient data is captured. Nationally convergent register allows for peer review of treatment outcomes. To complement registers’ clinical data, PROMs are collected with online MyHealth service to enable automatic, recurring data collection directly from the patient. The first questionnaire is activated 14 days before the visit, whereas new questionnaire is sent to the patient two months after visit, and then at time points according to the disease activity index calculated from the questionnaire. The disease activity is reflecting the severity of the IBD symptoms[1]. Captured measures are immediately available for clinician review. Results MyHealth for IBD is actively used in four Finnish university hospitals and two central hospitals with some inter-regional variation. By November 2021, the questionnaires were answered 31 506 times since the beginning of the implementation in 2019. The response rate is yearly increasing (Figure 1). Distribution of disease activity index among IBD patients in Tampere University Hospital is shown in Figure 2. Conclusion IBDR enables the evaluation and comparison of patient care quality, which is not accessible through EHR systems alone. Our electronic data collection model brings out the patients’ voice and saves resources since cyclic questionnaires are automatically send to patients, and answers are immediately reached by clinician. In future, international comparison and monitoring of treatment outcomes will be emphasized. As MyHealth deployment proceeds across hospitals, the availability of the patient reported outcomes data will increase. International research and peer development will continue to be an essential part of our activities. Reference 1. Puolanne A-M et al. Dig Dis Sci (2017) 62:3123–3130.

Role of portal color Doppler ultrasonography as noninvasive predictive tool for esophageal varices in cirrhotic patients

BackgroundEsophageal varices (EV) is the most common apprehensive complication of portal hypertension in patients with cirrhotic liver. Guidelines recommend Upper gastro-intestinal endoscopic screening for EV in patients with newly diagnosed chronic cirrhosis (Imperiale et al. in Hepatology 45(4):870–878, 2007). Yet, it is invasive, time consuming and costly. To avoid unnecessary endoscopy, some studies have suggested Doppler ultrasound examination as simple, and noninvasive tool in prediction and assessment of severity of EV (Agha et al. in Dig Dis Sci 54(3):654–660, 2009). Our study was to assess the role of different Doppler indices of portal vein, hepatic and splenic arteries as a noninvasive tool for prediction of esophageal varices in cirrhotic patients.ResultsThis prospective case control study was conducted on 100 cirrhotic liver patients and 100 of healthy volunteers as control group. Patients were subjected to clinical examination, upper gastrointestinal tract endoscopy, abdominal ultrasonography with duplex Doppler evaluation of different portal Doppler hemodynamic indices were done for each patient. The results revealed that portal vein diameter, hepatic artery pulsatility index, portal hypertensive index, portal vein flow velocity, portal congestion index have high sensitivity for prediction of EV. However, Splenic artery resistance index, hepatic artery resistance index HARI, liver vascular index and platelet count/spleen diameter have less sensitivity for prediction of EV.ConclusionMeasuring the portal hemodynamic indices can help physicians as noninvasive predictors of EV in cirrhotic patients to restrict the need for unnecessary endoscopic screening especially when endoscopic facilities are limited.

Hepatologist Perspectives Regarding Endoscopic Advances in Hepatology

Hepatologists have traditionally utilized a combination of clinical, laboratory, and imaging findings to diagnose and manage liver disease. Although endoscopy is routinely used for variceal detection and management, its role in hepatology more broadly has been limited. Recent advances in endoscopic ultrasound (EUS) have ushered in a new paradigm within advanced endoscopy and hepatology, termed “endohepatology.” 1 Chang KJ Samarasena JB Iwashita T et al. Endo-hepatology: a new paradigm. Gastrointest Endosc Clin N Am. 2012; 22 (xi): 379-385 Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Endohepatology has provided a new arsenal of techniques within the field of endoscopy, which include the ability to perform EUS-guided liver biopsies, portal pressure measurements, portal vein samplings, liver surface assessment, and ascites drainage/sampling. 1 Chang KJ Samarasena JB Iwashita T et al. Endo-hepatology: a new paradigm. Gastrointest Endosc Clin N Am. 2012; 22 (xi): 379-385 Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar ,2 Hashimoto R Chang KJ. Endoscopic ultrasound guided hepatic interventions. Dig Endosc. 2021; 33: 54-65 Crossref PubMed Scopus (3) Google Scholar These procedures are now in the early stages of being utilized in clinical settings, and demonstrations of feasibility have been shown. 3 Hashimoto R Lee DP Samarasena JB et al. Comparison of two specialized histology needles for endoscopic ultrasound (EUS)-guided liver biopsy: a pilot study. Dig Dis Sci. 2021; 66: 1700-1706 Crossref PubMed Scopus (7) Google Scholar ,4 Chang KJ. Endoscopic ultrasound-guided portosystemic pressure gradient and endo-hepatology. Gastroenterol Hepatol (N Y). 2021; 17: 181-183 PubMed Google Scholar

Patients With Adenocarcinoma of the Esophagus or Esophagogastric Junction Frequently Have Potential Screening Opportunities

Symptoms of gastroesophageal reflux disease (GERD) are risk factors for Barrett’s esophagus (BE) and esophageal adenocarcinoma (EAC). Guidelines recommend considering endoscopic screening for patients with GERD and additional risk factors. 1 Spechler S.J. et al. Gastroenterology. 2011; 140: 1084-1091 Google Scholar Screening programs can fail in the uptake of initial screening or of surveillance among those with known BE. Studies have demonstrated that fewer than 20% of patients with EAC had an esophagogastroduodenoscopy (EGD) before the diagnosis of cancer but were typically defined by EGD within just a few years before. 2 Tan M.C. et al. Aliment Pharmacol Ther. 2020; 52: 20-36 Google Scholar , 3 Wenker T.N. et al. Dig Dis Sci. 2018; 63: 3112-3119 Google Scholar , 4 Cooper G.S. et al. Am J Gastroenterol. 2009; 104: 1356 Google Scholar , 5 Dulai G.S. et al. Gastroenterology. 2002; 122: 26-33 Google Scholar Those studies also did not address whether there were potential opportunities to undergo screening. Such opportunities could include encounters for GERD, prescription of acid-reducing medications, or for colorectal cancer screening. We quantified the proportion and types of potential opportunities for screening and surveillance among individuals who later developed EAC. Because esophagogastric junction adenocarcinoma (EGJAC) shares many risk factors with EAC, we also explored the same opportunities for EGJAC.

Virtual Recruitment: Experiences and Perspectives of Internal Medicine Program Directors

Virtual Recruitment: Experiences and Perspectives of Internal Medicine Program Directors

Strategies to Improve Video Visit Use in Persons With Liver Disease

Strategies to Improve Video Visit Use in Persons With Liver Disease

Computer-Aided Diagnosis With Monochromatic Light Endoscopy for Scoring Histologic Remission in Ulcerative Colitis

Computer-Aided Diagnosis With Monochromatic Light Endoscopy for Scoring Histologic Remission in Ulcerative Colitis

ATYPICAL CHEST PAIN MAKES A SLIDING COME-UP INTO THE DIFFERENTIAL

SESSION TITLE: Medical Student/Resident Cardiothoracic Surgery Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: There are approximately 7.6 million annual visits for chest pain, making it the second highest cause for Emergency Department visits in the United States.1 A differential that is rarely considered yet possesses a high occurrence rate in the United States is hiatal hernia. Greater than 95% of hiatus hernias are sliding type I, while the prevalence of paraesophageal type II, type III, and IV hernias make up less than 5% of the cases.2 CASE PRESENTATION: 79-year-old female presented to the emergency department (ED) with a chief complaint of acute, 8/10 sharp chest pain that radiated to the midthoracic spine for a few hours before presentation. Associated symptoms included progressive dyspnea over the past few months. Her medical history was remarkable for diabetes mellitus type 2 and peripheral vascular disease. In the ED, patient was afebrile, pulse 106 bpm, respiration rate 31 bpm, blood pressure of 166/95 mm Hg, and pulse oximetry of 96% on room air. Pulmonary computed tomography angiogram (Figure 1A and B) showed a large left hiatal hernia containing the stomach and portions of the transverse colon and fat. Esophagogastroduodenoscopy (EGD) was performed which confirmed a large paraesophageal hernia with more than 75% of the stomach herniated and volvulized with incarceration in the chest, along with first part of the colon. The patient underwent successful laparoscopic repair of the hernia with esophageal mediastinal mobilization and gastropexy. The patient’s dyspnea and chest pain resolved over the following 3 post-operative weeks. DISCUSSION: The majority of patients with hiatal hernias are asymptomatic and are found incidentally on imaging. The only method of confirming a diagnosis of a hiatal hernia is with upper endoscopy or barium swallow. Both gastroesophageal reflux diseases (GERD) and obesity are risk factors that contribute to the development of a hiatal hernia. Studies show 50-94% of patients with GERD have a type 1 hiatal hernia as compared to 13-59% of normal.2 The result of delayed diagnosis increases the risk of complications such as gastric volvulus, gastric distension, gastric bleeding, erosions, or gastritis within the herniated pouch. Respiratory complications via mechanical compression of the lungs from the hernia or other organs herniating upwards is also frequently seen in large hernias.3 CONCLUSIONS: In summary, the consideration for hiatal hernias in patients presenting with chest pain should be especially heightened in the United States due to high rates of GERD and obesity. This case demonstrates chest pain as an uncommon chief complaint in patients with hiatal hernias and should be kept in the differential diagnosis of emergency and internal medicine physicians. Reference #1: 1.Rui P, Kang K, Ashman JJ. National Hospital Ambulatory Medical Care Survey: 2016 emergency department summary tables. 2016. Reference #2: 1.Wright, RA, Hurwitz, AL. Relationships of Hiatal Hernia to Endoscopically Proved Reflux Esophagitis. Dig Dis Sci 1979 Apr;24(4):311-3. Reference #3: 1.Weston, AP. Hiatal Hernia with Cameron Ulcers and Erosions. Gastrointest Endosc Clin N Am. 1996 Oct;6(4):671-9. DISCLOSURES: No relevant relationships by Katherine Fu, source=Web Response No relevant relationships by Dean Helseth, source=Web Response No relevant relationships by Israel Ugalde, source=Web Response

COVID-19: An Opportunity to Reimagine Colorectal Cancer Diagnostic Testing—A New Paradigm Shift

ABSTRACT Colorectal cancer is the third leading cause of cancer related deaths and to date, the COVID-19 pandemic has led to major disruptions of the diagnosis and treatment pathways of this cancer, which may adversely affect survival outcomes for many years. Colorectal cancer pathways must be maintained at a near normal throughput with urgent attention to the backlog of patients to avoid a potential crisis of avoidable cancer deaths. A radical review and revamping of endoscopy services to improve efficiency during COVID-19 is urgently required. To date most endoscopy units have severely restricted their activity, except for time-critical diagnostic and therapeutic procedures. In the post- COVID-19 recovery phase, access to endoscopy services will increase but capacity will be reduced compared to before the pandemic, due to infection control measures. A pragmatic and safe strategy is urgently needed to clear the backlog of endoscopic procedures and for managing the new symptomatic referrals. We propose the use of non-invasive tests, such as FIT and mSEPT9 combined with “safety netting” to “rule out” colorectal cancer and to reduce the utilization of colonoscopy by up to 80% and limit the procedure to those patients at high risk of cancer.