Emphysematous gastritis (EG) is a rare cause of abdominal pain, which should be differentiated from gastric emphysema. It is hypothesized to result from air-producing microorganisms in patients with underlying predisposing factors. Because of the non-specific presentation of EG, it is diagnosed radiographically. CT scan is the diagnostic modality of choice that typically reveals irregular, mottled appearance of the air in the thickened gastric wall and in the portal vein in the liver. We report a rare case of EG in a male with a history of diabetes mellitus who presented to the emergency department with diarrhea, nausea, vomiting, and epigastric pain. On examination, he was hypotensive and had mild tenderness in the epigastrium. Laboratory tests revealed leukocytosis, elevated lactate, anion gap metabolic acidosis, and acute kidney injury. A non-contrast CT abdomen revealed findings consistent with EG. Even though mortality rate in access of 60% have been reported without prompt surgical intervention in EG, recent literature suggests favorable prognosis with conservative measures in patients without an overt surgical indication. Our patient was also managed conservatively with IV antibiotics and gradual advancement of diet and had complete resolution of symptoms over the ensuing few days. The factors that correlate with a poor prognosis include elevated serum lactate, serum creatinine, and concomitant pneumatosis in small bowel and colon.

While generally safe, the most feared complication of colonoscopy is perforation of the colon, occurring in nearly 1 in 1,000 procedures, and is more common when polypectomy is performed and electrocautery is used. Less commonly known is the post-polypectomy electrocoagulation syndrome, a transmural burn of the colon which mimics the signs and symptoms of perforation as well as the time course, but follows a benign course and can be treated conservatively.

Patient: Female, 67Final Diagnosis: IVC filter perforation through duodenumSymptoms: Abdominal painMedication: —Clinical Procedure: EsophagogastroduodenoscopySpecialty: Gastroenterology and HepatologyObjective:Challenging differential diagnosisBackground:The number of IVC filter-related complications has increased with their growing utilization; however, IVC filter perforation of the duodenum is rare. It can manifest with nonspecific abdominal pain, gastrointestinal bleeding, cava-duodenal fistula, or small bowel obstruction.Case Report:A 67-year-old female presented with several years of right upper quadrant abdominal pain which was exacerbated by movement and food intake. She had a history of hepatic steatosis, cholecystectomy, and multiple DVTs with inferior vena cava filter placement. Physical exam was unremarkable. Laboratory tests demonstrated elevated alkaline phosphatase and transaminases. Esophagogastroduodenoscopy revealed a thin metallic foreign body embedded in the duodenal wall and protruding into the duodenal lumen with surrounding erythema and edema, but no active hemorrhage. Further evaluation with non-contrast CT scan revealed that one of the prongs of her IVC filter had perforated through the vena cava wall into the adjacent duodenum. Exploratory laparotomy was required for removal of the IVC filter and repair of the vena cava and duodenum. Her post-operative course was uneventful.Conclusions:In patients with history of IVC filter placement with non-specific abdominal pain, a high clinical suspicion of IVC filter perforation of the duodenum should be raised, as diagnosis may be challenging. CT scan and EGD are valuable in the diagnosis. Excellent outcomes have been reported with open surgical filter removal. Low retrieval rates of IVC filters have led to increased complications; hence, early removal should be undertaken as clinically indicated.

Hyperkalemia can present with a spectrum of clinical manifestations with progressive EKG changes and life-threatening arrhythmias. Although no formal guidelines exist as to when to initiate treatment for hyperkalemia, it is generally recommended in clinically symptomatic patients with or without EKG changes. Timely diagnosis and reversal can relieve symptoms and prevent life-threatening arrhythmias. We review the EKG changes associated with hyperkalemia and management principles along with an example of a case of severe hyperkalemia resulting in arrhythmia and flaccid paralysis.

The risk of venous thromboembolism (VTE) increases with age. New oral anticoagulants (NOACs) have been increasingly studied for VTE prophylaxis in patients with elective postarthroplasty. Although the elderly population accounts for a significant proportion of patients requiring VTE prophylaxis, safety and efficacy of NOACs in this subgroup for VTE prophylaxis has not been well studied. Relevant studies were identified through electronic literature searches of MEDLINE, EMBASE, Cochrane Library, and ClinicalTrials.gov (from inception to 12 August 2014). Phase III randomized controlled trials that compared NOACs against low-molecular-weight heparin (LMWH) in the prevention of VTE prophylaxis in patients with elective postarthroplasty were included. We defined our elderly population as adults of at least 75 years and assessed the reported safety and efficacy outcomes with NOACs in this population. Study-specific odds ratios (ORs) were calculated and between-study heterogeneity was assessed using the I statistic. In nine trials involving 29 403 patients, the risk of VTE or VTE-related deaths in elderly patients with elective postarthroplasty was similar with NOACs compared with LMWH (OR 0.62, 95% confidence interval 0.30-1.26; P = 0.18; I = 44%) but bleeding risk was significantly lower (OR 0.71, 95% confidence interval 0.53-0.94; P = 0.02; I = 0%). Analysis of individual NOACs showed superior efficacy but similar safety for apixaban when compared with LMWH. Efficacy and safety profiles of rivaroxaban and dabigatran were similar to LMWH. In elderly patients with elective postarthroplasty, NOACs have similar efficacy but superior safety when compared with enoxaparin for VTE prophylaxis.