November 2019

Volume 157Issue 5p1173-1444, e1-e28

In Memoriam

  • Kurt J. Isselbacher, MD (1925–2019)

    • Lawrence S. Friedman,
    • Daniel K. Podolsky
    Published online: August 08, 2019
    Kurt J. Isselbacher, MD, a towering figure in American Medicine who served as President of the American Gastroenterological Association and was a recipient of its highest awards, passed away on July 18, 2019, after a brief illness. He was 93 years old.

Covering the Cover

  • Covering the Cover

    • Andrew T. Chan,
    • Christopher S. Williams
    Published online: October 04, 2019
    A nationwide cohort study examined changes in risk of hepatocellular carcinoma after hepatitis C virus eradication among veterans.


Meeting Summary

  • Targeting Gut Microbiome Interactions in Service-Related Gastrointestinal and Liver Diseases of Veterans

    • Jasmohan S. Bajaj,
    • Arun Sharma,
    • Pradeep K. Dudeja
    • Collaborators
    Published online: August 09, 2019
    Open Access
    In response to a Request for Applications to support meetings to develop a novel roadmap for the Department of Veterans Affairs with focus on gastrointestinal (GI) illnesses that primarily affect returning veterans, a team of GI experts was invited to address these medical conditions affecting Veterans. A meeting was held on May 17, 2019, in San Diego, California, focused at developing a roadmap for targeting gut-microbe interactions in service-related GI diseases of veterans. This meeting was funded by Office of Research and Development (Dr Sharma and Dr Iqbal) and led by Dr Pradeep Dudeja and Dr Jasmohan Bajaj.
    Online ExtraAdditional Online Content Available

Mentoring, Education, and Training Corner

  • How to Perform a High-Quality PerOral Endoscopic Myotomy?

    • Mouen A. Khashab,
    • Amrita Sethi,
    • Thomas Rosch,
    • Alessandro Repici
    Published online: September 09, 2019
    Since its introduction by Inoue et al in 2010,1 peroral endoscopic myotomy (POEM) has become an accepted therapy for achalasia and an alternative to established treatments, such as pneumatic dilatation (PD) and laparoscopic Heller myotomy (LHM).2 POEM follows the principles of submucosal endoscopy and aims at disrupting the lower esophageal sphincter (LES), which results in clinical success in the vast majority of patients (>80%–90%).2,3 POEM is also safe and the rate of severe adverse events is very low when the procedure is performed by experienced operators.


  • Prophylactic Clip Closure Clarified: The Question Is Not Whether to Clip, But When

    • Douglas K. Rex
    Published online: September 04, 2019
    Hemostatic clips are established as effective to control active colonic bleeding,1 to prevent delayed perforation after endoscopic mucosal resection (EMR)-induced deep mural injury,2 and to close free perforations occurring during EMR3 and endoscopic submucosal dissection.4 A common use of clips has been prophylactic closure of colorectal polypectomy sites, with intent to prevent delayed hemorrhage. This use of clips is controversial, because efficacy data on prophylactic clipping are mixed and clips are expensive.
  • Can Colonoscopy Sow the Seeds of Colorectal Cancer?

    • James E. East
    Published online: September 20, 2019
    Colorectal cancer is a preventable disease.1 Bowel cancer screening whether via fecal immunochemical testing, flexible sigmoidoscopy, or primary colonoscopy, decreases the risk of future colorectal cancer significantly, and colonoscopy is the final common pathway in screening to remove polyps and prevent cancer1,2; however, despite this effectiveness, it has also become evident that colonoscopy is not perfect and cancers occur after a “clear” colonoscopy at a rate of between 2.5% and 8.7% of the total cancers diagnosed, depending on the method used to calculate and the population.

Gastroenterology in Motion

  • Strain-Photoacoustic Imaging as a Potential Tool for Characterizing Intestinal Fibrosis

    • Yunhao Zhu,
    • Laura A. Johnson,
    • Jonathan M. Rubin,
    • ...
    • Xueding Wang,
    • Peter D.R. Higgins,
    • Guan Xu
    Published online: August 13, 2019
    The accurate diagnosis of the composition of intestinal strictures is critical in the management of Crohn’s disease,1 Because inflammatory strictures may respond to anti-inflammatory therapy, but late-stage fibrotic strictures require surgical resection. In addition, the intestinal expression of extracellular matrix genes, that is, fibrosis, is an important predictor of future complicated and obstructive Crohn’s disease.2 Mucosal biopsies are limited by sampling depth, rarely reaching the muscular layers where fibrosis occurs.
    CME QuizVideo Abstract

Clinical Challenges and Images in GI

  • An Unusual Cause of Ileus in a Cardiovascular Surgery Patient

    • Charles Meade,
    • Magnus Halland
    Published online: June 19, 2019
    Question: An 82-year-old man was admitted for urgent coronary artery bypass and concurrent mitral valve repair. Intraoperatively, he underwent cardiopulmonary bypass, epicardial pacing, and placement of 2 anterior mediastinal and 1 pleural chest tubes. After a relatively unremarkable initial postoperative course and non-narcotic pain control, concern for ileus developed on postoperative day 4. A nasogastric tube was placed out of concern for worsening somnolence, nausea, and the inability to safely tolerate oral intake.
  • A Unique Cause of Gastric Polyposis

    • Alyssa Anderson,
    • Regina Plummer,
    • James M. Abraham
    Published online: June 27, 2019
    Question: A 62-year-old man with a history of coronary artery disease presented to our institution for evaluation of profound gastric polyposis after routine upper endoscopy for evaluation of progressive iron deficiency anemia. A family history was obtained and was remarkable for a daughter who died at age 32 from stage IV gastric adenocarcinoma in the setting of similar gastric polyposis; there was no known family history of colon cancer or other associated Lynch syndrome cancers. The presence of gastric polyposis preceded initiation of proton pump inhibitor therapy.
  • Currant Jelly-Like Clot-Induced Acute Pancreatitis

    • Mihaela Horumbă,
    • Alberto Larghi,
    • Mihai Rimbaș
    Published online: June 27, 2019
    Question: A 65-year-old woman was referred to our clinic with a 12-hour history of epigastric pain and coffee-ground emesis. Her medical history included hepatitis C virus-related compensated cirrhosis, for which she was currently undergoing treatment with an interferon-free regimen of ledipasvir and sofosbuvir for the last 2 months.
  • Sigmoid-Derived Neovaginal Hemorrhage in a Transgender Patient

    • Philip J. Riddle Jr.,
    • Farzin Rashti,
    • Divya Ahuja
    Published online: July 04, 2019
    Question: A 58-year-old transgender female who had intestinal vaginoplasty in Thailand in 2003 presented with intermittent vaginal bleeding and progressive weakness for 6 months. She reported frequent mucus production and episodes of gross blood soaking through several pads per day. Manual examination of the neovagina was unremarkable. Initial laboratory tests were significant for a hemoglobin of 6.1 g/dL, mean corpuscular volume of 71.5 fL, platelets of 195 K/μL, international normalized ratio of 1.3, and a partial thromboplastin time of 29.5 seconds.

Electronic Clinical Challenges and Images in GI

  • When Occam's Razor Meets Hickam's Dictum

    • Rochelle E. Wong,
    • Baldeep S. Pabla,
    • Anthony M. Gamboa
    Published online: May 28, 2019
    Question: A 59-year-old woman presented to our hospital with a 4-month history of progressive dysphagia. Her past medical history included a history of laryngeal squamous cell carcinoma for which she underwent radiation therapy in 2013 and cigarette smoking (40 pack-year history, recently quit 6 months ago). On physical examination, the patient’s neck was noted to have chronic radiation changes. A computed tomography scan of the neck demonstrated an 18 × 19 × 22-mm irregular enhancing mass-like lesion that seemed to arise from the anterior esophagus with abutment into the posterior wall of the trachea (Figure, A, B).
    Online Only
  • Itchy Hyperkeratotic Acral Plaque in a Patient With Chronic Calcific Pancreatitis

    • T.P. Afra,
    • Muhammed Razmi T,
    • Saleem Suhail
    Published online: May 29, 2019
    Question: A woman in her 40s complained of itchy, thick plaque of 5 years duration on her left foot. She had had a history of chronic calcific pancreatitis for which she had undergone Roux-en-Y lateral pancreaticojejunostomy followed by the Frey procedure some years later. She recalled the presence of a rash on both feet during this period. Even though she was on pancreatic enzyme replacement, she complained of occasional clay-colored stools. She was on topical steroids and oral antihistamines from multiple care providers for the cutaneous lesion with no significant improvement in her symptoms.
    Online Only
  • Enigmatic Abdominal Pain

    • Danmei Zhang,
    • Charles Maltz
    Published online: May 31, 2019
    Question: A 35-year-old man who had been in good health presented with several weeks of worsening abdominal pain, constipation, intermittent cramping, fatigue, and nausea. He was an office worker and had traveled to India about 2 months prior. Clinical examination revealed a tender and slightly distended abdomen. Initial evaluation included complete blood count, electrolytes, urinalysis, celiac serology, and liver function tests, which were all in normal range except for a normocytic anemia with a hemoglobin of 9.5 g/dL.
    Online Only
  • Incidental Jejunal Polyps

    • Eun Young Park,
    • Dong Hoon Baek,
    • Geun Am Song
    Published online: May 31, 2019
    Question: A 26-year-old man was referred to our hospital for an abnormality detected on a computed tomography scan of the abdomen. The patient had no medical or surgical history. He had no abdominal symptoms, such as nausea, vomiting, or abdominal pain. Physical examination was unremarkable. Initial laboratory studies, including routine blood test, carcinoembryonic antigen, and inflammatory markers were within the normal range.
    Online Only
  • New Ascites and Omental Thickening in Ulcerative Colitis

    • Joy C.Y. Chen,
    • Houssam Halawi,
    • Conor G. Loftus
    Published online: June 13, 2019
    Question: A 36-year-old man with ulcerative colitis presented to the hospital with 1-month of intermittent fever, abdominal distention, watery nonbloody diarrhea, and a nonproductive cough. He lives in the Midwestern United States and frequently travels to Brazil for his work. His ulcerative colitis had been well-controlled on infliximab monotherapy and a colonoscopy performed a year prior showed no active disease.
    Online Only
  • Clues From Ultrasound for an Infant With Failure to Thrive

    • Ya Ma,
    • Qian Jiang,
    • Zhengrong Wang
    Published online: June 13, 2019
    Question: A 3-month-old girl presented at our hospital with failure to thrive and abdominal distention. The pregnancy had been uneventful and had ended in a spontaneous vaginal delivery. The patient was apparently normal at birth and was born at term to healthy parents. Her older sister had died within 3 months of birth with the same manifestation.
    Online Only

Practical Teaching Cases

  • Bloody Diarrhea and Weight Loss in a Patient in Remission From Ulcerative Colitis

    • Lisa Tsang,
    • Natasha Banerjee,
    • James H. Tabibian
    Published online: March 01, 2019
    Question: A 22-year-old Latino man with a history of chronic ulcerative colitis (UC) and primary sclerosing cholangitis (PSC) was referred for inpatient gastroenterology consultation for a presumed UC flare. He reported several weeks of progressive abdominal pain, worst in the left lower quadrant, nausea, subjective fevers, bloody diarrhea, and unintentional weight loss. He received infliximab therapy for UC 6 years prior with complete resolution of symptoms, leading to self-discontinuation of therapy at age 18.
    CME Quiz
  • An Enigmatic Mass in the Ascending Colon

    • Aleksandar Gavrić,
    • Rok Dežman,
    • Borut Štabuc
    Published online: October 04, 2019
    Question: A 71-year old asymptomatic man with diabetes mellitus type II, hypertension, chronic kidney disease stage III, chronic obstructive pulmonary disease without inhalation therapy and hyperlipidemia was scheduled for an elective control colonoscopy. He performed screening colonoscopy one year ago due to positive fecal immunochemical test. The control colonoscopy was scheduled because during the first examination small adenoma (< 5 mm, Paris type 0-IIa) was described in the transversal colon but was not found and thus resected during withdrawal.
    CME Quiz

Original Research

Continuing Medical Education (CME)/MOC Activities

Selected Summaries


  • Ustekinumab and Pregnancy: Continue or Cease Before You Conceive?

    • Turki AlAmeel,
    • Eman Al Sulais
    Published online: September 09, 2019
    We read with interest the clinical pathway proposed by Mahadevan et al1 for the management of inflammatory bowel disease (IBD) in pregnancy. The authors recommended ustekinumab use throughout pregnancy with adjustment of the final dose to be several weeks before the estimated date of delivery. In our opinion, the statement made in the document lacks supporting evidence. To our knowledge, few case reports described the use of ustekinumab in pregnant patients with IBD. In 1 case report, a pregnant woman with Crohn’s disease on ustekinumab had a miscarriage at week 8.
  • Reply

    • Uma Mahadevan,
    • Susan Fisher,
    • Laura Riley,
    • Christina Chambers,
    • Rajeev Jain,
    • Christopher Robinson,
    • And the co-authors of the AGA Inflammatory Bowel Disease in Pregnancy Clinical Care Pathway
    Published online: September 09, 2019
    We thank the writers for their interest in our work. We would like to emphasize that this is a care pathway not a clinical guideline. A care pathway provides a practical application of available data. Clinical guidelines are far more rigorous and follow GRADE methodology and Institute of Medicine standards. The care pathway is by no means meant to be a substitute for such documents. Instead, this very practical document is meant to provide the best available evidence and an overview of the steps that should be taken when evaluating and treating pregnant women with inflammatory bowel disease (IBD).
  • Can Retrospective Studies Confirm Causes of Drug-Induced Liver Injury?

    • Ming Yang,
    • Zhiguo Li,
    • Dou Dou
    Published online: August 20, 2019
    Because of the significant academic influence of Gastroenterology, the article Incidence and Etiology of Drug-Induced Liver Injury in Mainland China has caused great impact in mainland China.1 We appreciate the dedication of Professor Mao Yimin and his team to drug-induced liver injury (DILI) research. However, there are several deficiencies in the study design and the research conclusion might be arbitrary. Those deficiencies could trigger readers’ to have misunderstand the incidence and etiology of DILI.
  • RE: Incidence and Etiology of Drug-Induced Liver Injury in Mainland China

    • Harshad Devarbhavi,
    • Einar S. Bjornsson
    Published online: August 20, 2019
    We read with great interest the article by Shen et al1 on the Incidence and Etiology of Drug-Induced Liver Injury in Mainland China. The number of cases suspected of drug-induced liver injury (DILI) reported (>25,900!) is impressive, and by far the largest number reported in any study on DILI so far. The article is generally well-written. However, there are several important issues that needs to be taken into consideration which makes interpretation of the results very difficult.
  • RE: Incidence and Etiology of Drug-Induced Liver Injury in Mainland China

    • Weihong Cong,
    • Qiqi Xin,
    • Yueqiu Gao
    Published online: August 20, 2019
    We read with interest the recent article published in Gastroenterology by Shen et al,1 which reported findings of a retrospective study that determined the incidence and causes of drug-induced liver injury (DILI) in mainland China, and the leading cause of DILI was traditional Chinese medicines (TCM) or herbal and dietary supplements (HDS; 26.81%). Although this is the first large-scale estimate of DILI incidence and etiology in mainland China, there remain several critical issues inevitably making its conclusions to be reconsidered.
  • Reply

    • Tao Shen,
    • Yimin Mao,
    • Chengwei Chen
    Published online: September 09, 2019
    We have carefully read the letters from our peers who are interested in our work, which we explain and discuss below. The diagnosis at discharge are all made as drug-induced liver injury (DILI) for the initially screened 29,478 patients. According to the protocol, all these cases needed to be reevaluated by the Roussel Uclaf causality assessment method (RUCAM) or expert opinion process, which was recognized as assessment of causality, to confirm that they were probable or highly probable DILI cases.
  • Neonatal Life Events and the Risk of Inflammatory Bowel Disease

    • João Sabino,
    • Joana Torres,
    • Jean-Fréderic Colombel,
    • Inga Peter
    Published online: August 20, 2019
    We read with interest the report of Bernstein et al1 about early life events affecting the risk of later development of inflammatory bowel disease (IBD). Early life exposures are thought to modulate the risk for IBD and understanding disease risk-modulating events is quintessential to the efforts of preventing IBD. Therefore, we welcome this epidemiologic study and its contribution to the understanding of this important stage in the life of patients with IBD.