Career selection trends among recent gastroenterology fellowship graduates

Various career paths exist for gastroenterology (GI) fellowship graduates across the country. These include further training, clinical or nonclinical job opportunities. Clinical career paths for those seeking jobs include academic positions or nonacademic positions (nonacademic hospital employed and private practice jobs). Data regarding career placement trends are limited. This study aims to explore temporal trends in career selection among new GI graduates. This is an observational cohort study. A list of GI fellowship programs was obtained from the FREIDA American Medical Association database. Programs with sufficient information on past graduate or alumni career placement after fellowship between 2017 and 2022 were included. Baseline characteristics and relevant information were collected. A Chi-square test was performed to assess the relationship between the categorical variables. A total of 203 GI fellowship programs were reviewed, among which only 21% (43/203) reported sufficient graduate career information. Across the 43 programs, 636 graduates were included. Thirty-three percent (210/636) of graduates were female. Forty-eight percent (308/636) of the graduates pursued nonacademic positions (nonacademic hospital employed and private practice jobs), 34% (216/636) into academic positions, and 17% (112/636) elected to do additional fellowship training. Both males and females were more likely to be employed in private practice (X2 = 12.8, df = 2, P = .002). Navigating through the decision-making process of selecting the first job after fellowship can be challenging. Our study reveals higher preference for nonacademic roles among graduates, consistent over 5 years, suggesting need to explore obstacles for academic positions or further training.

A Gastroenterologist's Guide to Care Transitions in Cystic Fibrosis from Pediatrics to Adult Care

Cystic Fibrosis is a chronic disease affecting multiple systems, including the GI tract. Clinical manifestation in patients can start as early as infancy and vary across different age groups. With the advent of new, highly effective modulators, the life expectancy of PwCF has improved significantly. Various GI aspects of CF care, such as nutrition, are linked to an overall improvement in morbidity, lung function and the quality of life of PwCF. The variable clinical presentations and management of GI diseases in pediatrics and adults with CF should be recognized. Therefore, it is necessary to ensure efficient transfer of information between pediatric and adult providers for proper continuity of management and coordination of care at the time of transition. The transition of care is a challenging process for both patients and providers and currently there are no specific tools for GI providers to help ensure a smooth transition. In this review, we aim to highlight the crucial features of GI care at the time of transition and provide a checklist that can assist in ensuring an effective transition and ease the challenges associated with it.

A Percutaneous Endoscopic Colostomy Tube to the Rescue

Percutaneous endoscopic colostomy (PEC) tube placement is a minimally invasive procedure used to treat recurrent colonic pseudo-obstruction, sigmoid volvulus, chronic intractable constipation, and neurogenic bowel. PEC is a viable treatment alternative for patients who have failed conservative therapies and are deemed high risk for surgical management. We present a case of acute colonic pseudo-obstruction after Clostridioides difficile infection that was unresponsive to medical treatment or endoscopic decompression. A PEC tube was placed into the transverse colon with successful resolution of the colonic distension.

EUS-Guided Vascular Interventions

Endoscopic ultrasound (EUS) has numerous advanced applications as a diagnostic and therapeutic modality in contemporary medicine. Through intraluminal placement, EUS offers a real-time Doppler-guided endoscopic visualization and access to intra-abdominal vasculature, which were previously inaccessible using historical methods. We aim to provide a comprehensive review of key studies on both current and future EUS-guided vascular applications. This review details EUS-based vascular diagnostic techniques of portal pressure measurements in the prognostication of liver disease and portal venous sampling for obtaining circulating tumor cells in the diagnosis of cancer. From an interventional perspective, we describe effective EUS-guided treatments via coiling and cyanoacrylate injections of gastric varices and visceral artery pseudoaneurysms. Specific attention is given to clinical studies on efficacy and procedural techniques described by investigators for each EUS-based application. We explore novel and future emerging EUS-based interventions, such as liver tumor ablation and intrahepatic portosystemic shunt placement.

Analysis of Reported Adverse Events Associated with Over-the-Scope Endoscopic Suturing System: an FDA MAUDE Database Study

PURPOSE

The over-the-scope endoscopic suturing system (ESS) (OverStitch™) is one of the most widely utilized endoscopic suturing systems in current clinical practice; however, data on the adverse events associated with this device is scarce. Our study aims to evaluate the adverse events and complications associated with the over-the-scope ESS using the FDA's Manufacturer and User Facility Device Experience (MAUDE) database.

MATERIALS AND METHODS

We analyzed the post-marketing surveillance data from the FDA MAUDE database for the over-the-scope ESS from January 2008 through June 2022.

RESULTS

Eighty-three reports were filed from January 2008 to June 2022. Adverse events were classified as device-related complications and patient-related adverse events. Seventy-seven device-related issues and 87 patient adverse events were identified. The most common device-related issue was difficulty to remove after deployment (n=12, 15.58%) followed by mechanical problem (n=10, 12.99%), mechanical jam (n=9, 11.69%), or entrapment of device (n=9, 11.69%). Of the 87 patient-related adverse events, the most common was perforation (n=19; 21.84%), followed by device embedded in tissue or plaque (n=10; 11.49%), and abdominal pain (n=8; 9.20%). Of the 19 patients who experienced perforation, two required open surgical repair and one required laparoscopic surgical repair.

CONCLUSION

The overall adverse events from the over-the-scope ESS remain acceptable as evidenced by the number of reported cases since 2008. However, it is important to note that adverse event rates might increase as the use of the device increases; therefore, it is essential for endoscopists to be aware of the potential common and rare adverse events associated with the use of the over-the-scope ESS device.

A Curious Case of Rectal Ejaculation

Rectal-prostate fistulas are uncommon anatomical connections between the prostatic urethra and rectum that are typically iatrogenic but can also result from other underlying pathology. Here, we present a unique case of a rectal-prostate fistula causing the rectal passage of sperm.

A 33-year-old male with a history of illicit drug use presented with five days of testicular pain and a substantial amount of sperm passage from his rectum with ejaculation for the past two years. Computed tomography and voiding cystourethrogram (VCUG) of the pelvis revealed evidence of a rectal-prostate fistula. He was treated with piperacillin-tazobactam, and a surgical fistula repair was performed. Further investigation divulged a three-week comatose state due to cocaine and phencyclidine intoxication two years prior with documentation suggesting a traumatic Foley catheter placement and strong suspicion for premature balloon dilation in the prostatic urethra. Repeat VCUG revealed resolution of the fistula with mildly reduced antegrade ejaculatory volume.

Cases secondary to Foley catheter placement have not been previously reported in the literature. Even though urethral catheters have been shown to be effective tools in healthcare, it is crucial for clinicians to recognize the numerous potential complications that oftentimes become an afterthought to many providers. This case not only highlights a rare complication of catheter use but also emphasizes the importance of provider mindfulness when utilizing seemingly benign therapies such as Foley catheters.

Severe Hypertension Leading to Hemorrhagic Stroke in Neurofibromatosis Type 1

Neurofibromatosis type 1 (NF-1), also known as von Recklinghausen’s disease, is an autosomal dominant multisystem genetic disorder affecting one in 2,600 individuals. It is caused by a mutation of the NF-1 gene located on chromosome 17q11.2. It is characterized by various cutaneous findings, including cafe-au-lait spots and axillary freckling. Hypertension is a commonly reported finding in adult patients with NF-1 but may also develop during childhood. In most cases, hypertension in NF-1 patients is primary in nature; however, secondary hypertension has been more frequently reported in NF-1 patients due to the association of NF-1 with an increased incidence of pheochromocytomas, bilateral renal artery stenosis, and coarctation of the abdominal aorta. This case reports the consequences of uncontrolled hypertension in a 23-year-old female with NF-1, illustrating the importance of screening for hypertension in children diagnosed with NF-1, and emphasizing the higher incidence of both primary and secondary causes of hypertension in the NF-1 patient population. In this case, no secondary causes of hypertension were found; therefore, a diagnosis of primary hypertension was made and the appropriate therapy was initiated to prevent further complications.

Life-Threatening Intraventricular Rupture of Brain Abscess in a Patient With Undiagnosed Hereditary Hemorrhagic Telangiectasia

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant genetic condition associated with mucocutaneous and visceral arteriovenous malformations (AVMs), including pulmonary AVMs, which predispose patients to systemic paradoxical emboli that can lead to brain abscesses. Intraventricular rupture of brain abscess (IVROBA) is a feared complication with a high mortality rate. Here, we present a case with brain abscesses complicated by IVROBA and ventriculitis as the initial presentation of HHT in an undiagnosed patient. We also discuss the diagnostic and therapeutic approach that resulted in this patient’s clinical improvement.

Accuracy of endoscopic ultrasound in esophageal cancer staging

Since its advent in the 1980s endoscopic ultrasound (EUS) has played an important role in the diagnosis, staging, and therapeutic management of various gastrointestinal malignancies. EUS has emerged as a vital tool in the evaluation of esophageal cancer as it provides a detailed view of the layers of the esophageal wall and surrounding tissues. This permits determination of tumor invasion depth and local lymph node metastases. It is the most sensitive and specific method available for locoregional staging of esophageal cancer. The information obtained via EUS is vital in determining the appropriate diagnosis, prognosis, and treatment options. Thus, this article aims to present a review of the accuracy and utilization of EUS in the staging of esophageal cancer.

Acute lymphoblastic leukemia presenting with mesenteric ischemia

Malignancy can induce a hypercoagulable state and lead to an increased risk of thromboembolic events. The pathogenesis of the prothrombotic state in cancer is complicated but is thought to involve several mechanisms. Thrombosis predominantly affects the venous circulation and infrequently the arteries. Arterial occlusion as an initial manifestation of acute leukemia is unusual. This is a case of a 44-year-old male admitted with complete thrombotic occlusion of the superior mesenteric artery and treated with emergent thrombectomy. Hematologic work-up was consistent with a diagnosis of T-cell acute lymphoblastic leukemia. To our knowledge, this is the first case of complete occlusion of the superior mesenteric artery presenting as the initial manifestation of T-cell acute lymphoblastic leukemia.

Lemierre’s Syndrome Due to Methicillin-Resistant Staphylococcus aureus

Lemierre’s syndrome is an uncommon and potentially fatal complication of oropharyngeal and facial infections. It involves an associated septic thrombophlebitis, bacteremia, and septic emboli. Traditionally, compromise of the internal jugular vein has been described in conjunction with an infection caused by anaerobes, especially, Fusobacterium necrophorum. In recent years, however, variant forms have been appearing, including other vessel compromise and other etiologic agents. We present the case of Lemierre’s syndrome in a 31-year-old male with facial vein thrombosis, septic emboli to the lungs, and bacteremia caused by methicillin-resistant Staphylococcus aureus. We hope that this case will raise awareness about variant presentations and promote a timely diagnosis and appropriate treatment of this potentially fatal infection.