The advent of direct-acting antiviral (DAA) treatments for chronic hepatitis C virus (HCV) infection has dramatically increased rates of cure. However, there remain difficult-to-treat populations, including patients with genotype 3 infection and cirrhosis, and limited salvage treatment options for those that have failed first-line DAA therapy. Areas covered: This is a review of the preclinical and clinical development of sofosbuvir/velpatasvir/voxilaprevir (SOF/VEL/VOX), an interferon-free, oral, once daily, pangenotypic treatment for chronic HCV infection. All relevant literature from 2015 through June of 2017 is included. Expert commentary: Voxilaprevir, a second-generation HCV protease inhibitor, in combination with the already approved combination of sofosbuvir and velpatasvir, was evaluated in the POLARIS trials and found to be a safe and effective regimen. Patients with prior DAA treatment failure, genotype 3, cirrhosis and/or unfavorable resistance profiles all achieved cure rates of 96% or greater. The most distinctive role for this potent regimen may prove to be as a salvage regimen for patients who have failed previous DAA therapy.

Tracheoesophageal fistula without associated esophageal atresia (H-type) is a rare congenital anomaly, accounting for about 4% of esophageal malformations. However, it can occasionally be seen in adults with chronic cough and respiratory infections. We present a 38-year-old woman with a new diagnosis of H-type tracheoesophageal fistula.

The Instinct clip, when used for UGIB, seems to be safe and effective with similar rebleeding rates compared with other modalities.

INTRODUCTION: Mirizzi's syndrome (MS) is a rare complication, occurring in around 1% of all cholecystectomies and affecting around 0.1% of all patients with gallstones (GS). MS occurs when an impacted GS in the neck of the gallbladder (GB) or cystic duct (CD) causes compression of the common bile duct (CBD) or common hepatic duct (CHD), resulting in obstruction and potential progression to a cholecystocholedochal fistula. MS is usually managed by surgery. We report a rare case of a critically ill patient who was successfully cleared of obstructing stones via ERCP after failed surgery, allowing the patient to undergo subsequent successful heart transplantation. CASE DESCRIPTION/METHODS: A 42-year-old male with a history of coronary artery disease and ischemic cardiomyopathy presented with cholangitis due to CBD obstruction. Despite successful ERCP duct clearance, he was deemed not to be a surgical candidate due to severe cardiac morbidities. Months later he represented with cholangitis and was found on ERCP to have a CBD/CHD obstruction due to a large stone, originating from the CD, which was filled with many large stones. He underwent an attempt of GB resection. However, safe GB resection was precluded due to profound adhesions, complete tissue plane loss, and extensive fibrosis. GB wall debridement and removal of multiple large gallstones was surgically attempted to alleviate the CBD/CHD obstruction. A follow-up ERCP for stent removal showed persistent MS, thereby precluding the patient from heart transplant listing due to persistent cholangitis risk. Three subsequent ERCPs with aggressive SpyScope exploration of the CBD/CHD and CD, electrohydraulic shockwave as well as mechanical basket lithotripsy within the CD, and basket and balloon stone fragment removal resulted in complete clearance of all CD and CBD/CHD stones. Shortly afterwards, the patient presented with decompensated heart failure and underwent successful heart transplantation. DISCUSSION: MS presents a significant challenge to clinicians. The treatment is surgical, although inflammation, adhesions, and associated tissue plane distortion pose a challenge to even the best surgeon with an increased risk of bile duct injury. ERCP allows for diagnostic confirmation and biliary drainage via stent placement to alleviate the obstruction and cholangitis. We describe the successful implementation of ERCP as definitive therapy by utilizing a multitude of tools to clear the CD, CBD/CHD stones after failed surgery.

A middle-aged gastroenterologist with a history of wellcontrolled hypertension and impaired fasting glucose was repeatedly hospitalized for hypertensive crises. Several weeks prior to presentation, the patient began to experience episodes of searing "hot poker" occipital headache immediately followed by facial flushing and neck rash associated with blood pressures (BPs) >170/ 120 mm Hg while performing endoscopy, all of which resolved following completion of the procedure. Of note, the endoscopist was required to rotate and extend his neck to view video monitors while performing endoscopy. These episodes continued to intensify, and the patient required seven hospitalizations during a period of 3 weeks for stabilization and treatment of BP values exceeding 230/130 mm Hg.The patient's medical history was significant only for hypertension well controlled with a single agent and impaired fasting glucose not requiring medication. He did not have any toxic habits or psychosocial stressors. He did not have a history of neck trauma, surgery, or radiation. He did not have a family history of pheochromocytoma.Physical examination of the patient was significant for orthostatic hypertension and an erythematous rash on his neck. An increase in BP >30 mm Hg could be elicited with neck rotation, chewing, and talking. With an arterial line in place, the patient's BP was observed to instantly increase whenever he rotated his neck to the left, as he would when performing endoscopy. There was no carotid or abdominal bruit. Funduscopic examination found no evidence of chronic hypertensive changes.Comprehensive serologic testing included electrolytes, renal function, hepatic function, thyroid function, catecholamines, renin, aldosterone, serotonin, dopamine, chromogranin, and tryptase, which were within normal limits. Results from urine catecholamines, metanephrines, and 5-hydroxyindoleacetic acid were within normal limits. Comprehensive imaging including magnetic resonance imaging and magnetic resonance angiography of the brain, neck, and abdomen; cardiac catheterization; and whole-body positron emission tomographic, octreotide, and radiopharmaceutical metaiodobenzylguanidine scans failed to find an adrenal tumor or extra-adrenal paraganglioma or carotid glomus tumor. Nocturnal oxygen saturation did not fall below 90%. Tilt table autonomic testing, performed once while the patient was taking antihypertensive medications, was inconclusive.The patient's BP was ultimately stabilized on a regimen of amlodipine and labetalol. He does, however, continue to have occasional breakthrough episodes and can intentionally elicit them by rotating his neck to the left. Because of the disabling nature of his condition, the patient retired from his practice.