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Introduction: Cytomegalovirus (CMV) infection in severe ulcerative colitis (UC) is thought to either be the cause or the result of steroid resistant ulcerative colitis. The cause of this discrepancy is due to conflicting study results. These occur because of poor detection techniques for CMV in tissue samples compounded by unclear distinction between the type of inflammatory bowel disease (i.e. Crohn's vs UC) affected in the case description. Our goal is to add to the existing body of evidence of CMV infection in UC towards improving evidence based management and care and also highlight the diagnostic and management conundrum prevailing at this time through the following case. Case Description/Methods: A 69 year old male presented in the outpatient setting with several months of bloody diarrhea and was found to have UC of the whole colon through colonoscopy. Biopsy results did not find any dysplasia nor granulomata. CMV immunohistochemistry was negative. Patient was on Sulfasalazine for two weeks before he presented for inpatient admission with voluminous bloody diarrhea ongoing for several days. After Clostridioides Difficile (CDiff) testing was negative, steroid therapy was started. After 3 days, steroid resistant disease was determined and patient was transitioned to Infliximab with some initial improvement. He had significant deterioration after 4 days of treatment and was then found to be CDiff positive for which oral Vancomycin was initiated. A flexible sigmoidoscopy was performed, revealing extensive inflammation with spontaneous bleeding and evidence of ulceration. Biopsy results indicated CMV coinfection this time. Intravenous Ganciclovir treatment was initiated. However, patient had no improvement after three days of antiviral therapy and hence underwent colectomy with end ileostomy. Discussion: Current guidelines recommend treatment with 14 days of Ganciclovir in CMV infection in UC. However, due to conflicting evidence, they do not recommend delaying colectomy until a full course of antiviral medication management is complete. As surgical intervention, especially those resulting in stoma, have significant negative burden on quality of life for patients, it is important to expediently work towards evidence based consensus on treatment and management of this condition. Improving the quality and quantity of clinical data through case reports and series along with better detection techniques for CMV are the first steps towards this goal.

INTRODUCTION: Gastroesophageal reflux disease is a common condition that often requires long term medical management or elective surgery in the form of fundoplication. Advanced endoscopic techniques can potentially be able to supply a safer alternative for patients with reflux disease. We propose a natural orifice transluminal endoscopic surgical technique that uses a self-approximating submucosal tunnel approach to the mediastinum to perform an anti-reflux procedure. CASE DESCRIPTION/METHODS: An acute porcine model was used for this acute animal feasibility study. Female Yorkshire pigs were kept on a liquid diet for forty eight hours and nothing by mouth eight hours prior to endoscopy. All animals were anesthetized and monitored. A four to five centimeter long submucosal tunnel is created in the posterior esophagus, beginning about ten centimeters above the gastroesophageal junction. From inside the tunnel, the muscles are incised to gain entry into the mediastinum. The esophagus is then followed down to the diaphragmatic hiatus and the right and left crura are located. The aorta, the vagal nerves, and other surrounding structures are identified. Using an overstitch device fitted on a double channel scope, we then suture the crura posteriorly, effecting a cruroplasty. Following the procedure, the animals were euthanized and immediate necropsy was performed to assess for any complications as well as determine the success of the cruroplasty. Esophageal pressure was assessed endoscopically in one animal. DISCUSSION: A submucosal tunnel was successfully achieved in all three animals with safe entry into the mediastinum. Mediastinal and then peri hiatal anatomy was demonstrated in each animal with excellent view of the thoracic aorta, esophagus, right and left vagus nerves, lungs, and the diaphragmatic crura. Endosuturing was successful with effective cruroplasty in all three animals without complications. Necropsy showed that sutures were in correct anatomical location without signs of procedural complication. We conclude that it is entirely possible to access the diaphragmatic hiatus and perform endoscopic cruroplasty for the potential treatment of reflux disease. A survival study aimed at developing a full-fledged anti reflux procedure is currently underway. We speculate that a trans-esophageal approach can provide an easy and safe treatment option for selected patients suffering from reflux disease. Watch the video: http://bit.ly/2JQiEaF