No abstract

Colorectal cancer is one of the most commonly diagnosed cancers worldwide. Traditionally, mechanisms of colorectal cancer formation have focused on genetic alterations including chromosomal damage and microsatellite instability. In recent years, there has been a growing body of evidence supporting the role of inflammation in colorectal cancer formation. Multiple cytokines, immune cells such T cells and macrophages, and other immune mediators have been identified in pathways leading to the initiation, growth, and metastasis of colorectal cancer. Outside the previously explored mechanisms and pathways leading to colorectal cancer, initiatives have been shifted to further study the role of inflammation in pathogenesis. Inflammatory pathways have also been linked to some traditional risk factors of colorectal cancer such as obesity, smoking and diabetes, as well as more novel associations such as the gut microbiome, the gut mycobiome and exosomes. In this review, we will explore the roles of obesity and diet, smoking, diabetes, the microbiome, the mycobiome and exosomes in colorectal cancer, with a specific focus on the underlying inflammatory and metabolic pathways involved. We will also investigate how the study of colon cancer from an inflammatory background not only creates a more holistic and inclusive understanding of this disease, but also creates unique opportunities for prevention, early diagnosis and therapy.

INTRODUCTION: Nearly half a million Americans suffered from Clostridium difficile (C. diff.) infections in a single year according to a study released by the Centers for Disease Control and Prevention (CDC). Studies indicate that C. diff. has become the most common microbial cause of Healthcare-Associated Infections found in U.S. hospitals driving up healthcare costs in acute care facilities alone. Our goal with this study is to investigate via retrospective chart review over the past 12 months to find out how often proper treatment was administered for patients admitted with a diagnosis of C. diff. infection. METHODS: This study is a retrospective chart review on patients admitted between Feb 2018–Feb 2019 at Franciscan Health St James Olympia Fields. Subjects were randomly selected with ICD-10 code for CDI. Age, gender, comorbidities, admission laboratory values, admission and discharge dates, and clinical course were obtained from EMR. The compliance to guidelines was assessed at initial treatment and as subjects further stratified into the categories non-severe, severe and fulminant disease. Compliance to guidelines was determined by type and duration of therapy. Secondary endpoints such as clinical outcomes such as 90-day mortality, therapy escalation and clinical cure which were also evaluated. RESULTS: A total of 118 patients were included in this study. This study shows that physician adherence to evidence-based guidelines for treatment of CDI was poor (50%). The study also found that compliance was lower in subjects with severe and fulminant disease. Overall, mortality associated with Clostridium Difficile treatment was 19.4% across all patients diagnosed with CDI regardless of severity of illness. CONCLUSION: CDI is a highly morbid condition and places a heavy burden on the healthcare system. Failing to adhere to the guidelines for treatment of Clostridium Difficile is detrimental to patients and results in worse clinical outcomes. This study identified that compliance to treatment guidelines is poor and barriers to compliance still exist despite education and guideline availability. To improve compliance to treatment guidelines in our hospital, we are currently developing an electronic order set through EPIC based on guidelines to allow for accurate treatment delivery and provide better outcomes.

Background: Anal fissures cause severe pain and can be difficult to treat. Medical therapy is initially used, followed by sigmoidoscopy-guided botox injections if the medical therapy is not successful. With this technique, however, it is not clear whether botox is injected into the muscle layer or submucosa. Aim: To evaluate the efficacy of EUS-guided botox injection directly into the internal sphincter. Methods: Consecutive patients with chronic anal fissure refractory to conventional endoscopic botulinum toxin type A injection were enrolled in the study. EUS was performed using a linear array echoendoscope, and a 25 G needle was used to inject botox. All patients were followed up at one- and two-month intervals. Results: Eight patients with chronic anal fissures were included in the study. Six patients had an excellent response to botox at the two-month interval using a visual analog pain scale, while one patient had a moderate response with a pain score reduction of 40%. One patient had no response. No complications were noted. An improvement in visual analog scale (pre-score > post-score) was statistically significant at the p < 0.01 level. Conclusion: EUS-guided botox injection into the internal sphincter appears to be a promising technique for patients with refractory anal fissure with pain.

Introduction: Gastrointestinal Stromal Tumors (GISTs) are rare neoplasm representing only 1% of all primary GI tumors. Yet they are the most common mesenchymal tumor (80%) of the GI tract with an age of onset usually between the seventh decade of life and a similar male-to-female ratio. GISTs can originate at any site from the esophagus to the anus and in fewer cases outside the GI tract. Therefore, having a wide range of presentation from asymptomatic to signs of acute abdomen. We report a case of a jejunal GIST causing chronic obstruction of the small intestine. Case Description/Methods: Case of a 54-year-old male, inmate with medical history of Hepatitis C arrives to the emergency department with complaints of intractable emesis and abdominal discomfort. The patient reports 8-10 episodes/day of gastric content vomiting that eventually turned bilious for the past 2 weeks. Furthermore, he refers having epigastric discomfort associated with fatigue, anorexia, and weight loss of 20 lbs since approximately 2 months ago. The patient denied any family history of gastrointestinal disease. On evaluation, he appeared chronically ill with signs of hypovolemic shock. Physical exam was remarkable for a peri-umbilical mass with no tenderness to palpation. Abdominal CT showed an exophytic soft tissue mass arising from the mid ileum that measured approximately 4.5 3 5.3 3 4.7 cm with associated slight swirling of the mesentery and upstream bowel loops, resulting in transition point and upstream dilatation of the small bowel compatible with a partial high grade small bowel obstruction. He underwent percutaneous biopsy with pathology report resulting in a spindle cell lesion, high risk, most consistent with GIST. Immunohistochemistry was only positive for C-KIT with a mitotic rate . 5/5 mm 2 . The patient had surgical excision of jejunal mass via small bowel resection and was discharged on tyrosine kinase inhibitor. At 6 months follow up, the patient was found disease free. Discussion: Occasionally, GISTs are found incidentally on imaging, predominantly in the stomach and small intestine, respectively. In our case, the patient presented with a KIT-positive jejunal GIST causing abdominal obstruction. Neoadjuvant therapy with Imatinib was given due to its elevated mitotic rate and high risk for progression. Early detection of these tumors requires a high level of suspicion hence the necessity of additional investigation to improve the prognosis and survival rates in this population.