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Peroral endoscopic myotomy (POEM) for achalasia (sometimes also referred as E-POEM to distinguish it from its offshoots such as G-POEM for gastroparesis or Z-POEM for Zenker's diverticula) is the newest treatment modality but has already been well validated as a standard intervention for esophageal achalasia. POEM was conceived as a Natural Orifice Transluminal Endoscopic Surgery (NOTES) procedure with an incisionless, endoscopic approach to myotomy. It matches or exceeds the efficacy of its surgical counterpart, the laparoscopic Heller myotomy, with superiority for type III (spastic) achalasia. There are issues however, especially regarding GERD after POEM that will likely result in further refinements of technique and post-procedural care. We will summarize the current status of POEM including description of technique variations and review of comparative data vis a vis Heller myotomy (HM) and pneumatic dilation (PD) and we will delve into some of the seminal issues around GERD assessment, management and prevention.

The novel coronavirus pandemic of COVID-19 has emerged as a highly significant recent threat to global health with about 600,000,000 known infections and more than 6,450,000 deaths worldwide since its emergence in late 2019. COVID-19 symptoms are predominantly respiratory, with mortality largely related to pulmonary manifestations, but the virus also potentially infects all parts of the gastrointestinal tract with related symptoms and manifestations that affect patient treatment and outcome. COVID-19 can directly infect the gastrointestinal tract because of the presence of widespread angiotensin-converting enzyme 2 receptors in the stomach and small intestine that can cause local COVID-19 infection and associated inflammation. This work reviews the pathopysiology, clinical manifestations, workup, and treatment of miscellaneous inflammatory disorders of the gastrointestinal tract other than inflammatory bowel disease.

COVID-19 infection is an ongoing catastrophic global pandemic with significant morbidity and mortality that affects most of the world population. Respiratory manifestations predominate and largely determine patient prognosis, but gastrointestinal (GI) manifestations also frequently contribute to patient morbidity and occasionally affect mortality. GI bleeding is usually noted after hospital admission and is often one aspect of this multisystem infectious disease. Although the theoretical risk of contracting COVID-19 from GI endoscopy performed on COVID-19-infected patients remains, the actual risk does not seem to be high. The introduction of PPE and widespread vaccination gradually increased the safety and frequency of performing GI endoscopy in COVID-19-infected patients. Three important aspects of GI bleeding in COVID-19-infected patients are (1) GI bleeding is often from mucosal erosions from mucosal infalammation that causes mild GI bleeding; (2) severe upper GI bleeding is often from PUD or stress gastritis from COVID-19 pneumonia; and (3) lower GI bleeding frequently arises from ischemic colitis associated with thromboses and hypercoagulopathy from COVID-19 infection. The literature concerning GI bleeding in COVID-19 patients is presently reviewed.

The global coronavirus disease-2019 (COVID-19) pandemic has caused significant morbidity and mortality, thoroughly affected daily living, and caused severe economic disruption throughout the world. Pulmonary symptoms predominate and account for most of the associated morbidity and mortality. However, extrapulmonary manifestations are common in COVID-19 infections, including gastrointestinal (GI) symptoms, such as diarrhea. Diarrhea affects approximately 10% to 20% of COVID-19 patients. Diarrhea can occasionally be the presenting and only COVID-19 symptom. Diarrhea in COVID-19 subjects is usually acute but is occasionally chronic. It is typically mild-to-moderate and nonbloody. It is usually much less clinically important than pulmonary or potential thrombotic disorders. Occasionally the diarrhea can be profuse and life-threatening. The entry receptor for COVID-19, angiotensin converting enzyme-2, is found throughout the GI tract, especially in the stomach and small intestine, which provides a pathophysiologic basis for local GI infection. COVID-19 virus has been documented in feces and in GI mucosa. Treatment of COVID-19 infection, especially antibiotic therapy, is a common culprit of the diarrhea, but secondary infections including bacteria, especially Clostridioides difficile, are sometimes implicated. Workup for diarrhea in hospitalized patients usually includes routine chemistries; basic metabolic panel; and a complete hemogram; sometimes stool studies, possibly including calprotectin or lactoferrin; and occasionally abdominal CT scan or colonoscopy. Treatment for the diarrhea is intravenous fluid infusion and electrolyte supplementation as necessary, and symptomatic antidiarrheal therapy, including Loperamide, kaolin-pectin, or possible alternatives. Superinfection with C difficile should be treated expeditiously. Diarrhea is prominent in post-COVID-19 (long COVID-19), and is occasionally noted after COVID-19 vaccination. The spectrum of diarrhea in COVID-19 patients is presently reviewed including the pathophysiology, clinical presentation, evaluation, and treatment.

BACKGROUND AND OBJECTIVE/UNASSIGNED:This narrative review discusses Barrett's esophagus management in the context of perceived deficiencies or controversies. Barrett's adenocarcinoma incidence has not clearly been impacted by Barrett's screening and surveillance. METHODS/UNASSIGNED:The following report was derived from articles using PubMed and Google searches. The search was concentrated on Barrett's esophagus screening and management guidelines. KEY CONTENT AND FINDINGS/UNASSIGNED:Comprehensive literature searches that highlight potential deficiencies or controversies regarding the current approach to Barrett's esophagus were employed. Esophageal adenocarcinoma incidence is rapidly increasing and this malignancy usually presents in an advanced and unresectable state. This is despite the significant expenditure of resources and time in endoscopic screening for and surveillance of Barrett's esophagus. Thus, more widespread screening for Barrett's esophagus may be considered. In addition, there are apparent inefficiencies and precision lack in the performance of endoscopic surveillance. This relates mainly to the lack of endoscopic cues for dysplasia. On the other hand, relatively low-risk subjects have frequent screening or surveillance procedures increasing cost. Lastly, endoscopic ablation for Barrett's with dysplasia has moderately good efficacy, especially for eradication of dysplasia, but mandates intensive post-therapy endoscopic surveillance. There is some concern for subsurface development of advanced Barrett's lesions. Fortunately, there is intense research in improving Barrett's esophagus diagnosis and treatment. Our narrative review will delineate deficiencies and potential measures to remedy them. CONCLUSIONS/UNASSIGNED:In conclusion, screening for Barrett's esophagus and surveillance in Barrett's subjects have minimal established benefits, but proposed changes in screening practices and innovations in Barrett's esophagus endoscopic surveillance and dysplasia therapy have great promise.

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is commonly utilized to treat pancreaticobiliary diseases and is considered safe in pregnancy. We describe a case of ERCP indicated for choledocholithiasis in a newly pregnant patient which resulted in a very rare complication related to guide wire trauma. Case Description/Methods: A 24-year-old female presented to the emergency department with right upper quadrant pain, fever, leukocytosis, and obstructive jaundice. Bloodwork revealed she was 8 weeks pregnant. Imaging studies showed acute cholecystitis and choledocholithiasis with a dilated common bile duct of 1.2 cm. Therapeutic ERCP was performed with minimal use of fluoroscopy to reduce fetal exposure. Double wire technique was utilized and the bile duct was successfully cannulated with a 0.025 mm angled-tipped hydrophilic wire. Sphincterotomy was performed, followed by sphincteroplasty. The bile duct was swept with a 12 mm balloon but only one stone was extracted. To avoid further fetal fluoroscopy exposure, double plastic stents were placed into the common bile duct and a single pigtail plastic stent was placed into the pancreatic duct. The following day, she became hemodynamically unstable. Labs suggested an improved cholestatic pattern and improved leukocytosis post ERCP decompression. Due to worsening hepatocellular injury and hemodynamic instability, a computed tomography angiogram was performed. A 3.9 cm subcapsular hepatic hematoma with capsular retraction and parenchymal distortion of the superior right hepatic lobe was found. Interventional radiology catheter embolization was attempted. Aggressive conservative management with blood transfusions and close monitoring successfully stabilized the patient. The patient ultimately had a spontaneous abortion and returned for an outpatient ERCP with biliary stent removal and stone extraction.
Discussion(s): Although a very rare complication, this case does highlight the possibility of angled-tipped hydrophilic guide wire hepatic trauma and clinically significant bleeding. When strongly indicated, ERCP should be performed in people who are pregnant, but exposure to fluoroscopy should be minimized. Similar cases hypothesize that liver injury is attributable to traumatic damage to the intrahepatic biliary tree and hepatic parenchyma by the ERCP guide wire. (Figure Presented)

Our tripartite narrative review discusses Peroral Endoscopic Myotomy (POEM), gastric POEM (GPOEM) and POEM for Zenker's diverticula (ZPOEM). POEM is the prototypical procedure that launched the novel "3rd space endoscopy" field of advanced endoscopy. It revolutionized achalasia therapy by offering a much less invasive version of the prior gold standard, the laparoscopic Heller myotomy (HM). We review in detail indications, outcomes, technique variations and comparative data between POEM and HM particularly with regard to the hotly debated issue of GERD. We then proceed to discuss two less illustrious but nevertheless important offshoots of the iconic POEM procedure: GPOEM for gastroparesis and ZPOEM for the treatment of hypopharyngeal diverticula. For GPOEM, we discuss the rationale of pylorus-directed therapies, briefly touch on GPOEM technique variations and then focus on the importance of proper patient selection and emerging data in this area. On the third and final part of our review, we discuss ZPOEM and expound on technique variations including our "ultra-short tunnel technique". Our review emphasizes that, despite the superiority of endoscopy over surgery for the treatment of hypopharyngeal diverticula, there is no clear evidence yet of the superiority of the newfangled ZPOEM technique compared to the conventional endoscopic myotomy technique practiced for over two decades prior to the advent of ZPOEM.

Inflammatory bowel disease (IBD) is commonly diagnosed and treated in the young population. Therefore, it is common that women anticipating or undergoing pregnancy will have to cope with the additional burden of their IBD. Pregnancy in an IBD patient also presents challenges for the practitioner, in that the usual diagnostic and therapeutic armamentarium of potential tests and therapies is disrupted. This review covers the implications of IBD for fertility, pregnancy and offspring, and discusses the management of IBD in pregnancy.