Gastric outlet obstruction (GOO) is a mechanical obstruction usually located in the gastric pylorus or duodenum. After the introduction of proton pump inhibitors (PPIs) in the late 1980s, most cases of gastric outlet obstruction are now caused by malignancy and peptic ulcer disease rarely leads to obstruction. We present a case of GOO caused by a large clot in the pylorus, preventing visualization of the source of bleeding. As the removal of the obstructing clot was deemed too high risk, the patient was treated with promotility agents that relieved the obstruction and allowed for the identification of the etiology of his upper gastrointestinal bleeding. Bleeding was definitively managed with embolization of the gastroduodenal artery.

Background: Patients (PTs) with Chiari malformation (CM) are prone to a wide variety of neurologic symptoms (SX), including headaches (HA), vision abnormalities, and nausea. These SX are attributed to impaired flow of CSF leading to benign intracranial hypertension (BIH). Occasionally, PTs with CM may require growth hormone therapy (GHT). This can potentially increase CSF accumulation and risk of BIH. The literature is limited to a small number of case reports on GHT in PTs with CM. Here, we describe the incidence of neurologic SX in 15 PTs. Methods: Our database was queried for PTs with CM who were treated with GHT from 2010–18 and records were reviewed for adverse events. PTs with neoplastic disease, active inflammation, or acute trauma were excluded. CM was defined as cerebellar tonsils located below the foramen magnum on MRI. Results: Mean and median ages of the 15 PTs (10 male, 5 female) who met inclusion criteria were 15.3 and 11.7 years, respectively. 14 were diagnosed as Type 1 and 1 was diagnosed as Type 2 CM. Tonsillar displacement ranged from 2-21mm, but was not specified in 5 PTs. Indications for GHT included isolated GH deficiency, panhypopituitarism, and chronic renal disease. Duration of GHT ranged from 0.2 to 12.25 years with a mean and median of 3.7 and 1.75 years, respectively. 7% (1 of 15) PTs experienced new-onset SX of BIH that could be attributed to GHT. 8 PTs (53.3%) did not experience any SX consistent with CM before, during, or after GHT. 3 PTs (20%) experienced neurologic SX prior to GHT. 1 PT reported diplopia and abnormal sleep patterns prior to GHT that resolved and did not recur during GHT. 1 PT prior to GHT manifested papilledema, 1 seizure, central sleep apnea, and occipital HA that resolved after posterior fossa decompression. Post-operatively and during GHT, this PT developed and continued to manifest nonpathologic pseudopapilledema. 1 PT continued to have pre-existing seizures and insomnia that did not worsen with GHT. 1 PT (7%) had congenital neurologic abnormalities in addition to CM. This PT had surgery to alleviate BIH caused by congenital hydrocephalus and SX permanently resolved. GHT has been continuous since birth with no new manifestations of CM reported post-operatively. 2 PTs (13%) developed new-onset neurologic SX while on GHT. 1 PT with diabetes experienced HA, 1 report of loss of consciousness, and 1 instance of apnea during periods of hyperglycemia. It was determined that these SX were unrelated to BIH and GHT was not interrupted. 1 PT experienced mild HA and 1 episode of occipital pounding with emesis during GHT. These SX resolved without intervention and GHT was continued without interruption. Despite the complexity of these cases, 0 PTs discontinued GHT. Conclusion: Our study demonstrates that in a majority (93%) of cases, GHT does not cause onset or worsening of SX of BIH in PTs with complicated and uncomplicated CM. GHT should be regarded as a safe treatment in these PTs.

Background: We have previously shown that short children have significantly reduced PVs. In this study, we further define the etiology of SS in a larger cohort of siblings (SBs). Objective: To further investigate the efficacy of PV as an indicator of poor growth. Patients and Methods:Methods: The database of a peds endo center was queried for SBs aged 6–18 yrs who underwent a GHST and subsequent MRI between 2013–19. Their MRI results were compared to randomly selected normal controls (NCs) aged 6–18 yrs seen at a neuroradiology center between 2010–16. Patients with MRI abnormalities were excluded. PVs were calculated using the ellipsoid formula (LxWxH/2). Our previous ROC curve analysis has defined 215.02mm3 and 315.00mm3 as cutoffs for small PVs in prepubertal and pubertal (PB) SBs, respectively (RSP). Growth hormone levels <10 ng/ml or >10 ng/ml diagnosed patients as growth hormone deficient (GHD) or idiopathic short stature (ISS), RSP. Patients: 77 SBs of 37 families were compared to 170 NCs. SBs <11 yrs and >11 yrs were considered pre-PB and PB, RSP. Results: The mean (MN) and median (MD) ages of SBs were 11.6 ± 2.2 and 11.9 yrs, RSP, and the MN and MD ages of the NCs were 12.6 ± 3.4 and 13.2 yrs, RSP. The difference (DIF) in MN age was significant (SG) (p<0.05). The pre-PB SBs and pre-PB NCs had MN and MD ages of 9.3 ± 1.2 and 9.7 yrs, RSP and 8.6 ± 1.4 and 8.6 yrs, RSP. The DIF in MN pre-PB age was SG (p<0.05). The PB SBs and PB NCs had MN and MD ages of 13.0 ± 1.4 and 12.7 yrs, RSP and 14.7 ± 1.9 and 14.6 yrs, RSP. The DIF in MN PB age was not SG (p<0.05). The MN and MD PVs for SBs (n=77) were 220.1 ± 94.0 and 204mm3, RSP. The MN and MD PVs for NCs (n=170) were 364.0 ± 145.2 and 346.0mm3, RSP. The DIF in MN PVs was SG (p <0.001). Stratified by age, the MN and MD PVs for SBs ages 6–11 yrs (n=29) were 166.1 ± 46.8 and 160mm3, RSP, and the MN and MD PVs for NCs ages 6–11 yrs (n=58) were 246.8 ± 63.7 and 241.6mm3, RSP. The DIF in MN PV was SG (p <0.001). The MN and MD PVs for SBs >11 yrs (n=48) were 252.7 ± 100.5 and 227mm3, RSP and the MN and MD PVs for NCs >11 yrs (n=112) were 424.6 ± 138.4 and 403.3mm3, RSP. The DIF in MN PV was SG (p <0.001). 86% of pre-PB SBs had small PVs, while 93% were GHD. 79% of PB SBs had small PVs, while 79% of PB SBs were GHD. 81.8% of all SBs had small PVs, while 84.4% were GHD. When combined, GHST and PV identify the etiology for SS in 96.1% of subjects. Discussion: The GHST recognized the etiology for SS in 84.4% of the SBs, while PV identified 81.8%. Using both criteria together, the etiology for SS was identified in 96.1% of the SBs. 3 of the 4 pre-PB SBs, who did not meet the PV cutoff had PVs within 10% of the cutoff. Conclusion: We have shown that PV is not inferior to the GHST in the diagnosis of SS. Combining the GHST and PV defines the etiology of SS in 96.1% of patients. Jointly, the GHST and PV should be considered the new gold standard for identifying children who qualify for GH therapy. This criteria will significantly diminish the number of patients diagnosed with ISS.

Introduction: Inflammatory bowel disease (IBD), further characterized into Crohn's disease or ulcerative colitis, is a chronic condition that involves immune-mediated inflammation and subsequent damage to the gastrointestinal tract. Treatment involves immunosuppression, increasing risk for infections and malignancies. Elevated cervical cancer rates are seen in these patients, and thus guidelines recommend annual cervical cancer screening in women receiving immunosuppressive therapy. Case Description/Methods: A 46-year-old female with Crohn's disease (diagnosed at 18) presented with left lower quadrant pain and bloating. Her disease was steroid-refractory and did not respond to mesalamine, azathioprine, or adalimumab. She was in remission for four years on infliximab, however, it was discontinued after a spontaneous mediastinal abscess. She was later treated with vedolizumab and eventually ustekinumab. She had a history of recurrent infections with a negative primary immunodeficiency workup. Computed tomography (CT) abdomen/pelvis revealed two large pelvic masses. Surgical pathology confirmed stage IVA cervical adenocarcinoma, human papillomavirus (HPV) independent, with involvement of the bilateral ovaries and fallopian tubes. CT abdomen/pelvis and Papanicolau smear with HPV co-testing performed less than a year prior to her cancer diagnosis were negative for evidence of malignancy. Discussion: Human papillomavirus (HPV) is the most common cause of cervical cancer. It has been hypothesized that HPV underlies the elevated cervical cancer risk in immunosuppressed patients. This case is notable as it involves an HPV-independent cervical cancer, found at an advanced stage, in a relatively young patient on immunosuppression. To the best of our knowledge, no similar reports have been described in the literature. Liquid based cytology pap smear and high risk HPV cotesting have demonstrated high sensitivity for cervical cancer screening. HPV-negative cervical cancers comprise only a small proportion of cervical neoplasms and are almost entirely adenocarcinomas. These cancers are often diagnosed at an advanced stage. ACG guidelines currently recommend annual screening for patients on immunosuppressive therapy. As in the case we have described, immunosuppressed patients can still develop advanced cancers between screening intervals. When caring for immunosuppressed IBD patients, there should be a low threshold for additional evaluation if patients develop signs or symptoms concerning for underlying malignancy.

Background: Preliminary studies have demonstrated improvement in metabolic control of patients (PTs) using subcutaneous Continuous Glucose Monitoring systems (CGMs). In this study, we investigated the effect of CGMs on PTs’ glycemic control and compared the change in patient HbA1c levels between sensors. Objective: To determine how CGMs affect metabolic control in PTs and the effect of different sensors on glycemic control. Patients and Methods: 33 PTs with Type 1 diabetes mellitus (DM) who began using a CGM between 2017 and 2019 were selected for inclusion. CGM systems used included DexcomG6™, DexcomG5™, DexcomG4™, Enlite™, Guardian 3™, or Medtronic Sure-T™ sensors. Results: The mean (MN) age of PTs at initial visit was 15.3 ± 5.1 yrs and the MN age at second visit was 15.8 ± 5.1 yrs. The MN time between visits was 5.0 ± 2.4 months (mos). 6 PTs had follow up (F/U) times less than 3 mos, 18 PTs had F/U times between 3 and 6 mos, 6 PTs had F/U times between 6 and 9 mos, and 3 PTs had F/U times greater than 9 mos. The MN and median (MD) HbA1c at the initial visit for all PTs was 8.28% ± 1.48 and 8.10%, respectively. The MN and MD HbA1c at final F/U for all PTs was 7.57% ± 1.11 and 7.50%, respectively. The difference in MN HbA1c was significant (p<0.001). The MN and MD HbA1c at the initial visit for PTs with a F/U time less than 3 mos was 7.55% ± 0.77 and 7.75%, respectively. The MN and MD HbA1c at F/U for these PTs was 7.20% ± 0.79 and 7.20%, respectively. The difference in MN HbA1c was significant (p<0.05). The MN and MD HbA1c at the initial visit for all PTs with a F/U time greater than 3 mos was 8.44% ± 1.53 and 8.10%, respectively. The MN and MD HbA1c at F/U for these PTs was 7.66% ± 1.15 and 7.50%, respectively. The difference in MN HbA1c was significant (p<0.001). The MN change of HbA1c between visits was not significant between PTs who had 3–6 mo, 6–9 mo, and 9+ mo F/U times (p=0.96) 15 PTs had HbA1c levels less than or equal to 8.0%. The MN and MD HbA1c at initial visit for these PTs was 7.20% ± 0.41 and 7.30%, respectively. The MN and MD HbA1c at F/U for these PTs was 6.75% ± 0.47 and 6.80%, respectively. The difference in MN HbA1c was significant (p<0.001). 20 PTs had HbA1c levels greater than 8.0% at initial visit. The MN and MD HbA1c at the initial visit for these PTs was 9.18% ± 1.47 and 8.80%, respectively. The MN and MD HbA1c at F/U for these PTs was 8.26% ± 1.03 and 8.00%, respectively. The difference in MN HbA1c was significant (p<0.001). The MN change in HbA1c between the high HbA1c group (-.92% ± 1.02) and low HbA1c group (-0.45% ± 0.32) was not significant (p>0.05). 25 PTs used a Dexcom™ sensor while 8 PTs used a Medtronic™ sensor. The MN change in HbA1c was not significant between these brands (p>0.05). Conclusion: CGMs improve metabolic control in pediatric PTs with Type 1 DM regardless of initial HbA1c. Further, this improved control is sustained over time. Sensor brands appear to be equally effective at achieving this goal.