Purpose of Review Hepatobiliary complications are common in Roux-en-Y gastric bypass (RYGB) patients. Despite development of multiple surgical and endoscopic access techniques over the years, ERCP using standard duodenoscope remains challenging in these patients due to the altered anatomy. Recent Findings Limited success with enteroscope-assisted and laparoscope-assisted ERCP led to the evolution of the novel EUS-directed transgastric ERCP (EDGE) procedure, with variations of this technique termed as Gastric Access Temporary for Endoscopy (GATE), EUS-guided TransGastric ERCP (EUS-TG-ERCP), EUS-guided GastroGastrostomy-assisted ERCP (EUS-GG-ERCP), and EUS-directed transgastric intervention (EDGI). EDGE has high technical (100%) and clinical success rates (60–100%), lower adverse event rate (1.5–7.6%), and up to 20% access stent migration rate; without any significant weight changes. EDGE has significantly shorter procedure time (73vs184min), post-procedural hospital stays (0.8vs2.65 days) and is more cost effective compared to other modalities. Summary EDGE technique addresses the challenges of RYGB anatomy as a minimally invasive, clinically successful, fully endoscopic, and cost-effective option. We present a literature review of the EDGE technique from its inception to current, in addition to reviewing other access techniques, their advantages, disadvantages and outcomes.

Cannabis hyperemesis syndrome (CHS) is a clinical syndrome associated with prolonged and regular cannabis use. CHS is characterized by recurrent episodes of intractable nausea and vomiting. Given the overlap with other medical conditions and the frequent delay in diagnosis, finding an effective anti-emetic regimen for symptomatic control of CHS can be challenging. We report a case study where aprepitant (Emend) was successfully used as an anti-emetic in the treatment of CHS when all other common anti-emetics failed.

INTRODUCTION: The rising obesity epidemic in the US has led to an increase in bariatric surgeries, and Roux-en-Y gastric bypass (RYGB) is a common option. These patients are at higher risk for gallstone disease, but the resulting altered anatomy presents unique challenges to accessing the bile duct. Lap-assisted ERCP (LAERCP) is the most common modality for biliary access in this setting but leads to high resource utilization and morbidity. EUS-directed trans-gastric ERCP (EDGE), is emerging as a new alternative. We present a comparison between the performances of LAERCP and EDGE in RYGB patients at our institution. METHODS: The protocol was approved by the institutional review board. Charts were reviewed for all RYGB cases that underwent LAERCP or EDGE at our health system between 5/2009 – 5/2019. Patient demographics, procedural and clinical information was gathered. Both groups were compared using students T test for continuous variables and Pearson’s chi square and Fisher exact test for categorical variables. RESULTS: A total of 76 RYGB patients (17 EDGE and 59 LAERCP) were analyzed. The mean age, gender and indication for the procedure (biliary vs pancreatic) were similar in both groups. All EDGE and LAERCP were performed in a single step setting. Technical success of obtaining access to the excluded stomach was 100% for both groups. There was no statistical difference in the technical success of therapeutic ERCP between the two groups (94% EDGE vs 100% LAERCP). There was no difference in the adverse event rates between EDGE (6%) and LAERCP (17%). The EDGE group had significantly shorter procedural time as compared to LAERCP (103 vs 208 min, P < 0.001); but there was no difference in the length of hospital stay (2.7 vs 2.6 days, P = 0.94). The median time for lumen-apposing metal stent removal was 22 days (range 0-111). There was no significant weight gain (-6.33 lbs) at median follow up of 35 days in the EDGE group. CONCLUSION: Overall success rate of intended therapeutic intervention and adverse event profile are similar for EDGE and LAERCP. EDGE has significantly shorter procedure time and can be done independently in the endoscopy unit, unlike LAERCP which requires operating room availability and coordination with a skilled laparoscopic surgeon. EDGE can be considered as a safe and effective first line modality for pancreaticobiliary access in RYGB patients offering the benefit of repeat ampullary access if needed on follow up procedure and without any worries of significant weight gain.

Clostridium difficile infection is a common nosocomial infection in US hospitals, accounting for approximately 12 800 deaths annually in the United States. These infections are often associated with the use of antibiotics, which can alter the gut microbiome and thus render patients susceptible to C difficile infection. C difficile is often spread via fecal oral transmission. Multiple medications have been developed, but recurrence rates reach 60% after treatment. Recent data have shown that zinc supplementation decreases the recurrence of C difficile infection. In this article, we present a case of recurrent C difficile infection with zinc deficiency in which zinc supplementation improved the symptoms and reduced the incidence of recurrence.

Following the first report of COVID-19 infection in December 2019 as a respiratory illness, it has proven to be a multisystem disease. There are few reported cases of ischemic colitis with COVID-19 infection in the medical literature to date and we have limited understanding of its pathophysiology. We report 2 cases of ischemic colitis as the only manifestation of COVID-19. In addition, we review the current limited literature regarding COVID-19-associated ischemic colitis.