Background/AimsLiterature on the safety of endoscopic retrograde cholangiopancreatography (ERCP) in elderly patients is divided. Based on this we decided to examine the safety of ERCP in nonagenarian patients.MethodsA total of 1,389 patients, with a mean age of 63.94±19.62 years, underwent ERCP during the study period. There were 74 patients aged 90 years or older with a mean age of 92.07±1.8. Logistic regression showed that nonagenarian patients had a significantly increased odds of in-patient mortality (adjusted odds ratio [AOR]=9.6; 95% confidence interval [CI]=4, 23; p≤0.001). Charlson Comorbidity Index (CCI) ≥2 was also an independent predictor of in-patient mortality (AOR=2.4; 95% CI=1.2, 5.2; p=0.021). Age ≥90 was not associated with increased adverse events; however emergency procedures (AOR=2.4; 95% CI=1.5, 4; p<0.001) and CCI ≥2 (AOR=2.6; 95% CI=1.7, 4.0; p<0.001) were more likely to have adverse events. ConclusionsAge ≥90 and CCI ≥2 are independently associated with increased odds of in-patient mortality in patients undergoing ERCP, whereas emergency procedures and CCI ≥2 are associated with an increased adverse event rate. Caution must be exercised when considering ERCP in patients aged ≥90 years and those with a CCI ≥2.

Congestive heart failure (CHF) is a chronic disease process affecting multiple organ systems and is associated with significant morbidity and mortality. We report a case of a 43-year-old male with a history of unspecified cardiomyopathy who presented to the hospital with abdominal pain, distention, and nausea for 4 months. He was diagnosed with left ventricular noncompaction and gastroparesis. While symptoms of dyspnea, orthopnea, or increasing peripheral edema are the first that come to mind when thinking of a CHF exacerbation, we must broaden our scope to include such things as nausea, vomiting, abdominal pain, and bloating which can also indicate worsening cardiac function. This case report highlights the significant yet often forgotten gastrointestinal (GI) symptoms that result from advanced biventricular heart failure, with emphasis on impaired gastric and intestinal motility.

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INTRODUCTION: Strongyloides Stercoralis infection affects as many as 30 million people in 70 countries worldwide. It also can undergo cycles of autoinfection leading to chronic disease. This infection is usually asymptomatic and may remain undetected for decades. However, in patients who are immunocompromised, such as patient’s undergoing chemotherapy, receiving long-term corticosteroids, transplant patient, or patient with HIV; severe infection can occur and result in mortality rates as high as 87%. Strongyloidiasis is difficult to diagnose as the parasite load is low and the larval output is irregular. CASE DESCRIPTION/METHODS: 79-year-old Chinese migrant man with metastatic lung adenocarcinoma who was recently started on Erlotinib, presented with nausea, vomiting, diarrhea, generalized weakness, and epigastric pain. He had White Blood Cell count of 7.6 with 6.6% Eosinophils. X-ray and Computed Tomography imaging did not show any changes from prior studies. Esophagogastroduodenoscopy was performed afterwards which showed esophagitis, gastritis, duodenal ulcer and duodenitis. Subsequently, biopsies of the duodenal and esophageal mucosa revealed parasitic larvae consistent with Strongyloides Stercoralis (Figure 1). The patient was started on Ivermectin and had resolution of his symptoms on follow up. Erlotinib was resumed after discharge. DISCUSSION: Although differential diagnosis for esophagitis in immunocompromised patients is broad, our patient was interestingly diagnosed with Strongyloides induced esophagitis via biopsy. The larvae of Strongyloides have potential ability to invade and survive for extended periods in human tissue. They have obligatory tissue phase in which the larvae follows from the portal of entry and eventually to trachea and lung. Depressed cell-mediated immunity secondary to malignant tumor, combined with protein-calorie malnutrition, led to lack of granulomatous immune response to larvae in our patient. Several immunodiagnostic assays have been found ineffective in detecting disseminated infection. Although it is important to detect latent S. Stercoralis infections before administering chemotherapy or before the onset of immunosuppression in patients at risk, a specific and sensitive diagnostic test is lacking. When acute esophagitis does present, it may be severe and disabling, and could result in hospitalization, placement of a feeding tube in the stomach or parenteral nutrition, and steady supportive care. Biopsy, cytology, and culture are recommended for suspected cases.