bluuebunny/crossref_metadata_2025 huggingface dataset:
2140 Management of Recurrent Sigmoid Volvulus Using Dual Endoscopic Modalities of Sigmoidopexy and Percutaneous Colostomy Placement
Authors: Kantrowitz Michael , Grunwald Matthew , Tsirlin Yuriy , Adler Harry , Rhee Rebecca , Khodorskiy Dmitriy O.
Published: October 2019

INTRODUCTION:

Sigmoid volvulus (SV) occurs when the colon twists about its mesentery which can compromise vascular perfusion leading to ischemia. Mortality rate (MR) is up to 60%, requiring emergent endoscopic (ES) detorsion via flexible sigmoidoscopy (FS) with placement of a rectal tube. Recurrence is high, ultimately requiring surgical management. The mean age of presentation is 70 with high likelihood of multiple comorbidities, resulting in high surgical risk. We present a case of ES therapy of recurrent SV.

CASE DESCRIPTION/METHODS:

88-year-old man with colon cancer status post left hemicolectomy (LH), coronary artery disease on antiplatelet agents, atrial fibrillation on anticoagulation, congestive heart failure, and chronic pulmonary disease, presented with abdominal pain, distention and obstipation for two days. The patient had a history of three episodes of SV requiring ES detorsion since LH. Abdominal x-ray revealed a markedly dilated sigmoid colon. Emergent FS was performed with insertion of a 36 French (Fr) catheter resulting in decompression. Computed tomography (CT) was unrevealing for other pathology. Colonoscopy showed a severely redundant, tortuous and dilated colon without other abnormalities. Subsequently, ES sigmoidopexy was performed under fluoroscopy to minimize looping and confirm SV detorsion. Six T-fasteners (TF) were placed cephalocaudally, 5-10 cm apart, with the first TF upstream to proximal region of twisting and the sixth TF downstream to distal region of twisting. A 16 Fr percutaneous endoscopic colostomy (PEC) tube was then inserted as a decompression valve. The tube was affixed to the abdominal wall with two additional TFs inserted adjacent to the third TF to create a triangle within the region of previously dilated lumen. The eight TFs and PEC tube were tightened to abdominal wall, and the tube was connected to a Foley drainage bag. Follow up CT scan confirmed resolution of SV. The patient improved clinically and was discharged home after having formed bowel movements.

DISCUSSION:

Due to high MR, a high index of suspicion for SV is necessary in elderly patients presenting with abdominal distention. Although several case series exist describing ES sigmoidopexy and laparoscopically-assisted PEC tube insertion, to our knowledge this is the only described case of definitive ES therapy using both surgical and ES techniques. While additional cases are required to assess safety and efficacy, this technique may be an addition to the ES armamentarium in managing SV.
2145 Use of Sypbite Forceps to Successfully Remove a Proximally Migrated Biliary Stent: An Effective Alternative
Authors: Naseer Maliha , Mudireddy Prashant
Published: October 2019

INTRODUCTION:

Biliary stents are essential to therapeutic endoscopy. Although being useful in most cases, several complications are reported in literature. One of them is stent migration. We describe the retrieval of a proximally migrated biliary stent into left hepatic duct complicated by a liver abscess using a digital cholangioscope.

CASE DESCRIPTION/METHODS:

An 83-yrs-old male presented with abdominal pain for 3 days. Denied nausea, vomiting, fever or chills. Patient’s history was significant for pancreatic adenocarcinoma with common bile duct (CBD) stricture diagnosed 1 month prior to this presentation. He underwent ERCP with placement of a 10 F × 9 cm straight plastic stent in the CBD. Post ERCP he did well and was discharged home. A CT scan this admission showed proximal migration of the biliary stent into the left intrahepatic duct along with a fluid-gas collection in the left lobe of the liver. Labs showed leukocytosis, elevated bilirubin and liver enzymes. Patient underwent ERCP for retrieval of the migrated biliary stent. A biliary wire was successfully passed into the left intrahepatic duct. The biliary tree was then swept with three different sizes balloons, but the CBD stent did not move much and remained in the mid duct extending into the LHD. Decision was made to explore the CBD by spyglass. The SpyScope was advanced to the bifurcation. Biliary sludge was found in the entire main bile duct, occluding the stent. Using a spybite forceps the distal end of the stent in the mid duct was grasped and pulled along with the spyscope to the distal most part of the CBD. Major papilla was than dilated and CBD stent was removed using snare. Cholangiography confirmed brisk flow of contrast in entire biliary system. One 10 Fr by 7 cm double pigtail plastic stent was placed 7 cm into the common bile duct to prevent migration.

DISCUSSION:

Proximal migration of biliary stent in an infrequent occurrence with the reported incidence of 4.9%. Several endoscopic techniques have been described with success rate of 80%. Conventional techniques to retrieve migrated biliary stents includes grasping of the stent with rat-tooth forceps, traction retrieval, wire-guided retrieval basket, and snare. Use of SpyGlass cholangioscopy has been reported rarely for the removal of proximally migrated stent. SpyGlass is an effective way of visualization of the migrated stent and removal at the same time which can be used when conventional techniques fail.
2147 Adenomatous Polyp of the Biliojejunal Anastomosis and Bile Duct in a Familial Adenomatous Polyposis (FAP) Patient: A Multidisciplinary Approach to a Clinical Dilemma
Authors: Shah Ravi , Mehta Neal , Li Feng , Jang Sunguk , Yoon Ji Yoon , Mankaney Gautam , Kalady Matthew F. , Church James M. , Burke Carol A. , Walsh R. Matthew , Bhatt Amit
Published: October 2019

INTRODUCTION:

Duodenal cancer is the second most common malignancy in FAP patients, and advanced polyposis often requires duodenal resection. Post-duodenectomy FAP patients are at risk of developing polyps in the post-anastomotic jejunum. We present a challenging case of a post-duodenectomy FAP patient who developed adenomatous polyp at the biliojejunal anastomosis and bile duct.

CASE DESCRIPTION/METHODS:

A 36 year-old female with FAP, status-post proctocolectomy, pancreas-sparing duodenectomy for Spiegelman stage IV polyposis was found to have polyposis in the jejunum on surveillance capsule endoscopy. Push-enteroscopy revealed polyposis in the jejunum with a 15 mm polyp involving the biliojejunal anastomosis (Image 1). Given that this polyp was non-lifting, it was removed with hybrid endoscopic submucosal dissection (ESD) (Image 2). After polyp removal, there was suspicion the polyp extended into the distal common bile duct (CBD) which was confirmed with biopsies revealing low-grade dysplastic adenoma. After a multidisciplinary discussion, cholangioscopy with Habib EndoHPB radiofrequency ablation (RFA) (Boston Scientific, Marlborough, MA, USA) was planned (Image 3). The adenomatous tissue extended from the distal CBD to the proximal common hepatic duct (CHD) which was confirmed by biopsies. Biliary RFA treatment was inadequate evidenced by poor tissue response noted on cholangioscopy and repeat positive biopsies. We theorized that this was due to poor tissue apposition with the thin RFA catheter as there was no stricture. Given the patient’s young age, extent of bile duct involvement, and poor tissue response to RFA, we determined that a completion Whipple surgery would be the best long-term option.

DISCUSSION:

We present a unique case of a post-duodenectomy FAP patient with adenomatous polyp extending from the biliojejunal anastomosis to the proximal hepatic duct. We were able to remove the polyp at the biliojejunal anastomosis with hybrid ESD, but the biliary adenomatous tissue was not adequately treated by biliary RFA. The thin RFA catheter had poor contact on the bile duct wall as there was no stricture. If a balloon RFA biliary catheter existed that could provide better tissue contact with a normal diameter bile duct, maybe this could have been treated endoscopically. This case highlights the importance of multidisciplinary management of complex polyposis in FAP patients.
2148 A Mediastinal Abscess Due to Actinomcyes Odontolyticus Diagnosed by Endoscopic Ultrasound-Guided FNA
Authors: Halim Nasir , Theethira Thimmaiah , Roytman Marina , Saligram Shreyas
Published: October 2019

INTRODUCTION:

Thoracic Actinomyces is a rare infection but potentially aggressive. It is difficult to diagnose most often requiring surgical debridement. Actinomyces species colonize the mucosa of the body with disease potentially related to barrier injury.

CASE DESCRIPTION/METHODS:

A 29 year old male with history of childhood asthma and recent dental extraction presented with odynophagia. He noted chest discomfort & fevers. Physical exam revealed an obese male but was otherwise unremarkable. Oral exam was unrevealing for lesions. Labs noted a WBC of 16.8 u/L. CT Chest revealed a 5 × 2 × 2 cm posterior mediastinum collection (Figure 1) abutting the esophagus with mid and distal esophagitis. An EGD noted distal esophagitis, posterior extrinsic compression from 25 to 31 cm with a mucosal fistula at 27 cm with purulent drainage. Aspirated Esophageal contents were sent for culture. An IR Guided Drainage approach was not felt to be safe due to possibility of spinal injury. Patient underwent conservative treatment with PPI, Broad spectrum antimicrobial therapy. A repeat CT CAP revealed interval decreased size of mediastinal collection. Fluid cultures from endoscopy were negative. Testing for Coccidiomycosis, HIV, and Tuberculosis were negative. On Hospital Day 4, EGD and EUS was performed to evaluate the mediastinal abscess. EGD showed that the fistula had healed but there was esophageal rings and furrows; This was biopsied. The EUS noted a 1.5 × 2 cm Posterior Mediastinal Abscess. It was loculated and hard; A EUS guided FNA needle was used to obtain material for culture. Biopsies revealed >100 Eosinophil’s per HPF, consistent with esophinophilic esophagitis. FNA culture noted Actinomcyes Odontolyticus. Treatment was tailored for Penicillin-based therapy. On Hospital Day 12 , Repeat CT Chest did not identify a mediastinal collection or evidence of esophageal leak and noted resolving mural thickening of the esophagus.

DISCUSSION:

Thoracic actinomyces was diagnosed in the setting of active eosinophilic esophagitis. It is possible that EOE predisposes to Actinomyces as Actinomyces is a commensal flora of GI tract and this could have spread to mediastinum directly due to barrier injury. Increasing availability of endoscopic modalities may provide more accessible diagnostic options, which will help in targeted treatment. We report a possible association of EOE and Actinomyces and also successful minimally invasive diagnosis of actinomyces in a difficult anatomical location.
2154 In Situ Plastic Biliary Stents Causing Intestinal Perforation: A Case Series
Authors: Thapa Namisha , Loudin Michael , Sharzehi Kaveh , De Melo Silvio , Enestvedt Brintha
Published: October 2019

INTRODUCTION:

Intestinal perforation is a rare complication of plastic biliary stents which exclusively occurs in the setting of preceding stent migration. We present the first case series to our knowledge of four patients with intestinal perforation from non-migrated in-situ plastic biliary stents.

CASE DESCRIPTION/METHODS:

1: A 65-year-old-woman with biliary stent placement for cholangiocarcinoma-related obstruction presented with acute right upper quadrant (RUQ) pain. She had tachycardia, RUQ tenderness, and elevated liver function tests (LFT). CT scan showed duodenal perforation, and on ERCP a stent was seen perforating through the opposite duodenal wall. Prior straight 10Frx12 cm plastic stent was exchanged for a similar stent with a full external pigtail and a ½ internal pigtail. Over the scope clip was used to close the defect. 2: A 69-year-old-man with biliary stent placement for malignancy-related biliary stricture presented with acute RUQ pain. He had tachycardia, RUQ tenderness, and leukocytosis. CT scan showed duodenal perforation from distal tip of biliary stent with proximal aspect still in the common bile duct (CBD) though ERCP showed no obvious defect. Prior straight 10Frx10 cm plastic stent was exchanged for a similar stent with a full external pigtail and a ¾ internal pigtail. 3: A 60-year-old man with metastatic colorectal carcinoma of the liver with hepatic arterial infusion pump associated biliary sclerosis and stent placement presented with acute RUQ pain. He had leukocytosis, RUQ tenderness, and an acute LFT elevation. ERCP showed biliary stent causing duodenal wall ulceration. Prior 10 F × 12 cm plastic stent was replaced with a similar stent with a full external pigtail and ¾ internal pigtail. 4: A 24-year-old man with NASH cirrhosis status post orthotopic liver transplant and stent placement for anastomotic biliary stricture presented with acute LFT elevation. On ERCP, three plastic biliary stents were seen penetrating duodenal wall with proximal tips in place. Prior straight 10Frx12 cm plastic stents were replaced with similar stents with full external pigtail and a ¾ internal pigtail. An over the scope clip was used to close duodenal defect.

DISCUSSION:

Complication by in-situ plastic biliary stents may be decreased with full external pigtail stents. Stent exchange was successful in all cases, except case 4. This may have been due to the benign etiology of obstruction compared to malignant etiologies for others. An over the scope clip may be used successfully to close duodenal defect.
2156 Innovative Use of Linear EUS
Authors: Weinberger Jonathan , Grunwald Matthew , Waintraub Daniel J. , Ruggiero Maryanne , Rhee Rebecca , Mayer Ira , Khodorskiy Dmitriy O.
Published: October 2019

INTRODUCTION:

Therapeutic echoendoscopic ultrasonography (EUS) is vital in the diagnosis, staging, and tissue acquisition of gastrointestinal (GI) malignancies. However, its use is typically limited to upper GI tract and rectum due to limited visualization and instrument length. We present a case of evaluating an extraluminal lesion adjacent to the distal small bowel, utilizing a linear echoendoscope.

CASE DESCRIPTION/METHODS:

65 year old male with a history of cecal perforation in the setting of ischemic colitis (no pathologic evidence of malignancy), status post right hemicolectomy, COPD, DM and CHF was admitted with right sided abdominal pain without change in bowel habits. CT scan revealed a mass in the mid abdomen. The mass appeared inseparable from the small bowel (ileum) just proximal to the ileocolic anastomosis; however, it was unclear if the mass was extraluminal or invading the lumen. Colonoscopy was performed and there was no evidence of an intraluminal mass. Interventional radiology was contacted for biopsy of the mass, however, there was no safe window for biopsy. GI was re-consulted and a decision was made to attempt an EUS with fine needle biopsy (FNB) in order to avoid diagnostic laparoscopy. Ileum was intubated with a pediatric colonoscope and a 0.035 inch guidewire was advanced into the small bowel. Two endoclips were placed proximal to the ileocolic anastomosis for fluoroscopic guidance. The colonoscope was then exchanged for a linear echoendoscope which was advanced alongside the guidewire with an inflated forward balloon using endoscopic and fluoroscopic guidance. The mass was identified and FNB was performed. Cytology revealed atypical lymphoid cells consistent with high grade diffuse large B cell lymphoma.

DISCUSSION:

Linear echoendoscope is often used for evaluation of distal colonic lesions. Traditionally the miniprobe is used for diagnosis of lesions not reachable with a linear endoscope, but lacks the ability for tissue acquisition. Recently, a forward viewing echoendoscope has been developed however it is not yet widely available. We describe a case of an innovative use of linear echoendoscope in the proximal colon/distal small bowel, sparing a more invasive surgical procedure. In addition, we describe a novel use a forward balloon as a safety mechanism for advancing a side viewing endoscope in areas of limited visualization.
2162 Cryotherapy for Management of Transfusion-Dependent Gastrointestinal Hemorrhage Secondary to Gastric Antral Vascular Ectasia
Authors: Hanada Yuri , Wang Kenneth K.
Published: October 2019

INTRODUCTION:

Non-variceal upper gastrointestinal hemorrhage is traditionally managed with mechanical devices, thermal coagulation, or injection therapy. However, due to specific lesion characteristics, certain cases may not be easily or effectively managed by these methods, in which case either a novel therapy or repurposing of an existing technique could be considered. Here, we present a case of gastric antral vascular ectasia (GAVE) addressed with cryotherapy.

CASE DESCRIPTION/METHODS:

An 82 year old man with CAD s/p CABG, AS s/p AVR, symptomatic AVB s/p PPM, HTN, and BPH presented to his primary care provider Clinic with chronic, symptomatic, transfusion-dependent iron-deficiency anemia with a hemoglobin nadir of 6.7 g/dL from 12.2 g/dL four months prior. The patient also reported possible melena, though stool appearance was obscured by oral iron supplementation. He underwent diagnostic EGD, which identified severe GAVE with mild associated bleeding throughout the entire stomach. This was therapeutically managed with APC, but given the severity and diffuse nature of the GAVE (Figure 1), the patient was referred for cryotherapy. Medically, the patient was recommended to initiate PPI therapy and continue iron supplementation. Three sessions occurring at 1 month intervals were completed, followed by one session 3 months out. By the third session, the patient no longer required transfusional support to maintain appropriate hemoglobin levels. On endoscopic follow-up 6 months out (one year from initial EGD), the GAVE had improved in severity (Figure 2).

DISCUSSION:

The current treatment of GAVE primarily involves argon plasma coagulation, which is limited by its inability to treat large areas of mucosa in an efficient manner. However, data supporting the use of cryotherapy as a safe and effective treatment for GAVE are emerging. Patients with diffuse, extensive mucosal gastrointestinal lesions should be referred to a tertiary care center to assess cryotherapy candidacy.
2163 Successful Endoscopic Mucosal Resection for Duodenal Neuroendocrine Tumor: To Net a NET
Authors: Dharmadhikari Neal D. , Gao Tian , Yilmaz Osman , Shah Samir A.
Published: October 2019

INTRODUCTION:

Neuroendocrine tumors (NET) are rare (0.49 % of all malignancies) and slow-growing that can arise anywhere in the body from neuroendocrine cells. They are most commonly seen in the gastrointestinal tract, but compromise <2% of all gastrointestinal malignancies. NETs in the duodenum are even less common as they make up 2.6 % of all NETs. This case illustrates the appropriate diagnosis and management of a rare gastrointestinal malignancy – duodenal NET. Endoscopic mucosal resection (EMR) has become more common for the management of duodenal NETs, but guidelines are still evolving.

CASE DESCRIPTION/METHODS:

A 79-year-old male with a medical history of prostate cancer, stage 3 chronic kidney disease, gastroesophageal reflux disease with occasional dysphagia underwent an upper endoscopy which revealed a benign Schatzki ring that was dilated. A single 7 mm shiny nodule in the duodenal bulb was biopsied revealing a grade 1 NET. Endoscopic ultrasound (EUS) to assess showed the lesion measured 4.4 mm in thickness and 6 mm in diameter, originate within the submucosa and there was no surrounding lymphadenopathy. The lesion was raised by injecting it with a solution of epinephrine and methylene blue. A ligation-assisted endoscopic mucosal resection was completed. Pathology noted a well-differentiated grade 1 NET measuring 6 mm involving the submucosa and mucosa with no malignant cells noted in the margins. He returned home without any complications.

DISCUSSION:

The diagnosis of neuroendocrine tumors is difficult given their rarity, size, and potential asymptomatic presentation. For small, non-functional, localized duodenal NETs, resection is the goal and endoscopic therapy is becoming the preferred method of resection. Numerous surgical and endoscopic techniques have been explored; however, the optimal method has yet to be determined. This case shows the successful use of EMR after EUS evaluation in treating a duodenal NET with evidence of clean margins on pathology. We were able to describe a rarely encountered tumor and highlight the evolving use of advanced endoscopy in its management. Clinicians should be suspicious for NETs when encountering a shiny-appearing nodule in the gastrointestinal tract.
2165 Endoscopic Ultrasound-Guided Fine-Needle Biopsy (FNB) of a Liver Lesion Demonstrating Metastatic Esophageal Adenocarcinoma
Authors: Stadmeyer Peter , Akhter Ahmed , Barksdale Byron , Matkowskyj Kristina , Gopal Deepak
Published: October 2019

INTRODUCTION:

The role of biopsy in determining the etiology of hepatic lesions is crucial in determining pathology and potential therapy. Liver biopsies are often accomplished with the aid of interventional radiology with a percutaneous approach. However, there are instances when a percutaneous approach is not feasible. Here, we present a patient who underwent an endoscopic ultrasound (EUS)-guided fine needle biopsy (FNB) of a left lobe hepatic lesion which demonstrated metastatic esophageal adenocarcinoma.

CASE DESCRIPTION/METHODS:

A 76 year-old man with a history of esophageal adenocarcinoma, who previously underwent treatment with neoadjuvant chemoradiation and surgical resection 3 years earlier, was found on routine surveillance CT imaging to have a lesion within the left lobe of his liver. He subsequently underwent a PET CT that demonstrated this lesion to be FDG avid without any other evidence of FDG avidity (Figure 1). Interventional radiology was initially consulted for liver biopsy, however due to a poor window for access this could not be performed. He subsequently was referred for an EUS-guided FNB. EUS demonstrated a round to oval shaped, irregular mass within the left lobe of the liver. The mass was hypoechoic and heterogeneous with central spiculation. The mass measured 43 mm by 33 mm in maximal cross-sectional diameter. Color Doppler imaging was used prior to needle puncture to confirm a lack of significant vascular structures within the needle path. Fine needle aspiration for cytology was performed. Three passes were made with a 22-gauge FNB needle (Acquire™ 22ga) using a trans-gastric approach (1 pass for cytology touch prep, and 2 core biopsy samples for surgical pathology) (Figure 2). Preliminary rapid on-site cytological evaluation (ROSE) was suspicious for malignancy, with final specimen demonstrating adenocarcinoma. Surgical pathology from the core biopsy was reviewed and a diagnosis of metastatic adenocarcinoma, moderately differentiated, morphologically compatible with esophageal adenocarcinoma was rendered (Figure 3).

DISCUSSION:

This case demonstrates the utility and feasibility of an EUS-guided liver biopsy when a percutaneous approach is not possible to help make a diagnosis and direct therapy.
2166 Delayed Symptomatic Pneumoperitoneum After Peroral Endoscopic Myotomy (POEM)
Authors: McGrath Brian , Chen Huimin , Xia Liang , Chen Xiangbo , Abdelfatah Mohamed Magdy , Keilin Steven , Cai Qiang
Published: October 2019

INTRODUCTION:

Per-oral endoscopic myotomy (POEM) is as an effective and safe option for the treatment of achalasia. Symptomatic pneumoperitoneum, one of the most significant adverse events noted with POEM, generally presents during the periprocedural period and is treated with needle decompression. We report two cases of delayed symptomatic pneumoperitoneum that were recognized more than 24 hours after POEM, which has not been reported previously.

CASE DESCRIPTION/METHODS:

A 49-year-old female with history of achalasia presented with two-year history of dysphagia, 40lb weight loss, regurgitation, and chest pain that had been refractory to multiple esophageal dilations and botulinum toxin injections. She underwent an uncomplicated POEM and was admitted for observation. On post-procedure day 2, she complained of worsening shortness of breath and abdominal pain. Chest and abdominal radiographs revealed large volume pneumoperitoneum. Due to continued progression of pain and dyspnea, as well as persistence of pneumoperitoneum on imaging, she underwent CT-guided FNA decompression on post-procedure day 4, with 660 ml of air evacuated and improvement of pain and dyspnea. A 53-year-old female with history of achalasia presented with four-month history of dysphagia, 40lb weight loss, and regurgitation. She underwent an uncomplicated POEM and was admitted for observation. Approximately four hours after the procedure, she became febrile and tachycardic, concerning for perforation. She was transferred to the ICU, where physical exam revealed crepitus to the neck and chest, as well as diffuse abdominal tenderness without guarding or rebound. A chest radiograph revealed large volume pneumoperitoneum. Gastrograffin swallow showed no evidence of contrast extravasation or perforation. On post-procedure day 1, she underwent bedside ultrasound-guided needle decompression using a 16-gauge angiocatheter, which led to a rush of air and improvement in abdominal pain.

DISCUSSION:

While symptomatic pneumoperitoneum is the second most common adverse event associated with POEM, it has been reported exclusively in the immediate periprocedural period. The etiology of delayed symptomatic pneumoperitoneum in these cases is unclear. No precipitating factors were identified in the first case; in the second case, it is possible that the symptoms were due to a microperforation not detected on imaging. These cases illustrate the importance of continued vigilance for this complication outside of the immediate periprocedural period.
2174 Endoscopic Retrograde Cholangiopancreatography Leading to Necrotizing Fasciitis: A Case Report
Authors: Nasir Umair M. , Panchal Dayna , Choi Catherine , Ahmed Ahmed , Rodgers Brandon , Kutner Matthew
Published: October 2019

INTRODUCTION:

Endoscopic Retrograde Cholangiopancreatography (ERCP) had become the favored method to access the pancreaticobiliary system because its a safer less invasive method compared to surgery. However, as with any procedure ERCP comes with its own risks and potential complications. We present a unique case of patient who underwent and ERCP and developed necrotizing infection of neck and a submandibular abscess.

CASE DESCRIPTION/METHODS:

Patient is a 66-year-old female who presented to an outside hospital with complaint of right upper quadrant abdominal pain, workup revealed choledocholithiasis. ERCP was attempted however cannulation was unsuccessful. The patient was discharged home after the procedure, but within 48 hours she presented to our institution complaining of left sided neck pain, dysphagia, and drooling. Computed tomography of the neck revealed extensive gas and fluid collections at the left submandibular space. Patient was taken to the operating room for drainage of left deep neck abscess. Drainage and irrigation of the abscess yielded streptococcus mitis. Rest of patient’s hospital course was uncomplicated and patient was discharged with appropriate follow up.

DISCUSSION:

ERPC is a challenging gastrointestinal endoscopic procedures. Adequate volume of procedures is required to maintain proficiency and avoid complications. Uncommon complications such as perforation are reported in <1% of case. Perforations are most commonly reported in the esophagus, stomach, duodenum, periampullary region, and bile ducts. In the case of our patient, ERCP was complicated by a perforations of the hypopharynx. The most frequent cause of pharyngeal perforation is iatrogenic due to instrumentation commonly due to the advancement of the endoscope or endotracheal tube (ETT). Pharyngeal perforation can be subclassified into supraglottic and infraglottic. The latter is more commonly associated with advancement of an ETT during intubation and presents with blood in the ETT or decreased end tidal CO2 or decreased tidal volume. Advancement of endoscope in an already intubated patient can lead to a supraglottic tear which can present with bleeding observed outside of the ETT. Patients with supraglottic or infraglottic perforations can present with similar clinical symptoms of dysphagia, fevers, oral bleeding, subcutaneous emphysema of the neck. Quick identification and treatment can decrease the morbidity and mortality in such patients.
2180 Why Is This Hemoperitoneum Orange? A Late Diagnosed Isolated Rupture of the Gallbladder Secondary to Blunt Abdominal Trauma
Authors: Alansari Tarek H. , Alansari Ahmed , Vareedayah Ashley , Tzimas Demetrios , Harley Jennifer
Published: October 2019

INTRODUCTION:

The gallbladder is protected from blunt trauma by its unique anatomic position inferior to the liver and behind the rib cage. Biliary tree injuries are rare, occurring in approximately 2% of cases of blunt trauma. Isolated gallbladder injury is even rarer and the exact incidence is unknown.

CASE DESCRIPTION/METHODS:

48 year old male with a history of alcohol abuse who was brought to the Emergency Department with right upper quadrant pain after falling over a fan. Labs showed stable chronic macrocytic anemia and elevated liver function tests. CT revealed ascitic fluid with suspected hemoperitoneum. Surgery managed the patient conservatively in light of stable serial hemoglobin values. Over the next 4 days, the patient developed shock with multi-organ failure. Primary team presumed deteriorating clinical status was related to alcoholic hepatitis and acute on chronic liver failure. Gastroenterology was then consulted and we recommended urgent diagnostic paracentesis. When smeared, the fluid was dark orange in color. A Medicine resident called the GI fellow and asked “why is this hemoperitoneum orange?” Ascitic bilirubin was 25 mg/dL. Surgery believed it was due to hemolysis of the hemoperitoneum. We transferred the patient for urgent ERCP that revealed external accumulation of contrast and bubbles in proximity to the gallbladder. A common bile duct stent was placed. Patient was taken for exploratory laparoscopy where a 5 cm defect on the anterior wall of gallbladder was noted and cholecystectomy was performed. Postoperative course was complicated by a 9 × 7 cm intra abdominal abscess. The collection was not amenable to Interventional Radiology drainage due to its proximity to the spleen. The patient underwent successful endoscopic cystogastrostomy with placement of a lumen apposing metal stent.

DISCUSSION:

Isolated gallbladder injury remains challenging to diagnose both clinically and radiologically. When suspected, percutaneous drainage is indicated to establish diagnosis even if radiological investigations are unrevealing. There is a high risk of morbidity and mortality secondary to a missed or delayed diagnosis. For patients in whom diagnosis is delayed, abdominal sepsis secondary to non-sterile biliary peritonitis can complicate the postoperative course. ERCP can be performed prior to surgery to reduce the pressure gradient between the biliary system and the duodenum allowing bile to drain preferentially into the duodenum.
2182 Endoscopic Challenges in a Patient With Ansa Pancreatica and Recurrent Pancreatitis
Authors: Aaron Jacob , Ahmad Dina , Smith Zachary L.
Published: October 2019

INTRODUCTION:

Ansa pancreatica is a rare anatomical variation of the pancreatic duct where there is communication between the ventral pancreatic duct, which forms an ansa loop, and the accessory pancreatic duct. Its prevalence is estimated to be 1% in general population, and its presence can predispose to acute pancreatitis. We present an interesting and rare case of chronic pancreatitis with a pancreatic duct stricture in the setting of ansa pancreatica.

CASE DESCRIPTION/METHODS:

A 54-year-old female with a heterozygous CFTR mutation and a long-standing history of recurrent acute and now chronic pancreatitis. Two weeks after an episode of acute pancreatitis, a magnetic resonance cholangiopancreatography (MRCP) was performed showing a new stricture in the pancreatic duct near the genu, with pre-stenotic ductal dilation. Two prior endoscopic retrograde cholangiopancreatographies had been performed to attempt pancreatic duct endotherapy, but these were unsuccessful in achieving deep wire cannulation beyond the ansa loop. (image 1A-1B). The pancreatic duct in the genu of the pancreas was noted to have moderate stenosis on MRCP (image 1C). After a discussion with the patient, the decision was made to re-attempt endoscopic therapy. The ventral pancreatic duct was initially cannulated. The 0.025 inch angled guidewire was again unable to navigate the ansa loop and into the distal pancreas. Thereafter, we attempted dorsal pancreatic duct cannulation via the monir papilla. The guidewire was advanced successfully beyond the stricture and into the opacified body and tail (image 1D). The minor papilla and the stricture in the genu were dilated with a 7 Fr catheter dilator. After a minor papillotomy a 7 Fr by 8 cm plastic stent was placed into the dorsal pancreatic duct (image 1E, 2). The stent was removed 6 weeks later, and the duct remained patent. The patient has had no recurrence of acute pancreatitis to date.

DISCUSSION:

While the prevalence of ansa pancreatica is low, its presence can have great impact on the necessary approach for endoscopic therapy in chronic pancreatitis. In our case, the patient failed several ERCP attempts via ventral duct cannulation, and endoscopic therapy was successful only when cannulation of dorsal pancreatic duct was performed. In conclusion, in patients with chronic pancreatitis, recognition of ansa pancreatica, when present, is important to guide the endoscopic approach to treatment as minor papilla cannulation, a necessary skill for the interventional endoscopist, may be required.
2200 Ischemic Cholangiopathy Complicating an Orthotopic Liver Transplantation in Donation After Circulatory Death
Authors: Serrao Steve , Strilaeff Ryan , Che Kendrick , Rodrigues Medora , Bharadwaj Shishira
Published: October 2019

INTRODUCTION:

Livers from donation after circulatory death (DCD) donors have a higher incidence of poor functional status and ischemic cholangiopathy as highlighted in our case report below.

CASE DESCRIPTION/METHODS:

Here we present a case of a 64 year old male with end stage liver disease due to Hepatitis C cirrhosis complicated by HCC, with three episodes of TACE with a pretransplant MELD-Na 28 who underwent OLT from DCD donor with replaced left and right hepatic arteries. He presented with worsening liver enzymes on post-operative day (POD) 19. Initial labs suggested a hepatocellular liver injury pattern with total bilirubin 0.7 mg/dl, aspartate aminotransferase 116 U/L, alanine aminotransferase 286 U/L, and alkaline phosphatase 473 U/L. A post-transplant ultrasound indicated nonvascular hypoechoic areas in the right hepatic lobe possibly representing abscesses or areas of infarction. A vascular scan indicated decreased resistive indices and elevated systolic rise time in the right hepatic artery indicating hepatic arterial stenosis. A CT scan showed mild intrahepatic biliary ductal dilation with decompressed distal common bile duct (CBD) representing a possible anastomotic stricture. The liver biopsy showed minimal-mild portal infiltrates, without venulitis or ductulitis with mild lobular disarray and focal, mild cholestasis. Rare necrotic and degenerating hepatocytes, with focal drop-out were noted which showed active hepatitis. An ERCP was performed on POD 20. Necrotic and denuded biliary mucosa with a distal CBD stricture (Figure 1) was noted on cholangioscopy. Fluoroscopic images showed multiple intrahepatic strictures and cystic dilatation of several intrahepatic biliary ducts (Figure 2). Given the tightness of the stricture, only a A 7Fr x 7 cm plastic biliary stent could be placed across the stricture. Angiogram showed severe focal stenosis of the proximal right hepatic artery, just distal the anastomosis related to “kinking” of the vessel. Percutaneous Transluminal balloon Angioplasty resulted in wide patency after balloon dilation and placement of a 4 mm × 15 mm stent within the vessel (Figure 3). The middle and left hepatic arteries were patent.

DISCUSSION:

This case of DCD OLT complicated by ischemic cholangiopathy resulted in intrahepatic and CBD strictures requiring biliary stenting. What is unique in this case is the additionally stenosis of right hepatic artery, the inciting trigger which was re-perfused with a vascular stent and resulted in the stabilization of liver function.
2213 Graft-versus-Host Disease: A Rare but Lethal Complication After Liver Transplantation
Authors: Hasan Badar , Yim Yunjoo , Castaneda Daniel , Ur Rashid Mamoon , Al Khalloufi Kawtar
Published: October 2019

INTRODUCTION:

The Acute Graft-versus-Host Disease (GVHD) is one of the rare complications after liver transplant (LT) with prevalence up to 2%. Among solid organ transplant, intestinal transplant has the highest incidence followed by LT. Unfortunately, no universal treatment guidelines are available for this disease with poor outcomes and mortality up to 85%.

CASE DESCRIPTION/METHODS:

67-year-old male underwent orthotopic LT for end-stage liver failure due to Nonalcoholic steatohepatitis. CMV- patient received ABO identical cadaveric donor liver with CMV + serology. He had no peri-operative complications and was started on immunosuppression and antimicrobial therapies. Within 40 days of LT, he developed leukopenia and early transplant rejection, which was treated with medications. Within 100 days, patient developed rash on extremities and trunk that later spread to face, palms and soles. His course was further complicated by CMV seroconversion around 130 days post-LT. On day 168, patient presented with pancytopenia and continuing skin rash. The initial skin biopsy indicated drug induced reaction, but subsequent biopsy was consistent with GVHD. His treatment regime included steroid, tacrolimus, and rabbit Anti-thymocyte globulin (ATG) with broad-spectrum antimicrobials. Chimerism was initially 19% donor cells in the blood and it was 55% after 4 doses of ATG. He became septic and on day 209 succumbed to massive brain hemorrhage.

DISCUSSION:

GVHD after LT is in of the lethal complication that usually develops within 3-5 weeks. The key is to have a high index of suspicion with recognition of clinical signs; characteristic itchy palmar skin rash, diarrhea, fever, pancytopenia with normal LFTs. The symptoms are not specific and often diagnosed as infection or drug allergies. GVHD diagnosis can be established with skin lesion or GI tract biopsy and further confirmed with chimerism >30% in the blood of recipient. There is no consensus on treatment. Various strategies are adopted to suppress activated donor lymphocytes, including but not limited to, reduction or even withdrawal of immunosuppression, change in regimen with or without adding steroid boluses, IL-2 antagonist, antithymocyte/lymphocyte globulin, or use of OKT3. Broad-spectrum antimicrobial coverage is pivotal to prevent superimposed infection which is the main cause of death. Further studies are needed to raise the awareness among clinicians and to improve outcomes in patients who develop GVHD following LT.
2214 Acetaminophen-Induced Liver Toxicity in a Patient With Undetectable Acetaminophen Levels
Authors: Penmetcha Akhil , Goolsarran Nirvani , Namn Yunseok
Published: October 2019

INTRODUCTION:

Acetaminophen is a common cause of overdose related acute liver injury (ALI). However, patients using acetaminophen chronically may have undetectable levels on presentation. It is important to recognize acetaminophen induced ALI early during clinical presentation and treat it promptly to prevent acute liver failure (ALF).

CASE DESCRIPTION/METHODS:

72-year-old female with a history of osteoarthritis relieved by acetaminophen presented with severe right upper quadrant (RUQ) pain. On admission, temperature 38°C, blood pressure 119/73, and heart rate 111. Physical exam shows tenderness to palpation in RUQ, no guarding or rebound tenderness, negative murphy sign, complete alertness and orientation, and no asterixis. Laboratory findings show total bilirubin 1.6, direct bilirubin 1.0, ALT 2,133, AST 36,600, alkaline phosphatase (AP) 92, albumin 3.7, INR 1.6, ferritin 77,183, acetaminophen level < 5, alcohol levels undetectable. RUQ ultrasound showed reduced liver echogenicity. Given history of chronic acetaminophen use, patient started on n-acetylcysteine (NAC) protocol for 72 hours. During hospitalization, diagnostic testing showed: Iron, TIBC, and transferrin all within normal limits, hemochromatosis DNA testing negative, alpha-1 antitrypsin within normal limits, ceruloplasmin within normal limits, IgG serum within normal limits, ANA Ab screen negative, hepatitis A Ab IgM negative, Hepatitis B Core IgM, Surface Ag, Surface Ab all negative, Hepatitis C Ab negative, EBV and CMV negative, HSV IgM negative, anti-liver kidney microsomal antibody negative, anti-smooth Muscle Ab negative, AMA negative, MRI of liver not concerning for iron overload. While on NAC therapy, liver enzymes and function tests trended to normal limits and RUQ pain and fevers resolved. On discharge, bilirubin and AP were within normal limits, ALT 305, AST 61, albumin 3.6, ferritin 8002 (Figures 1 and 2). 2-week post discharge follow up with primary care provider showed liver enzymes within normal limits.

DISCUSSION:

In this case, although acetaminophen levels were undetectable, careful elicitation of patient history gave clinicians more reason to suspect acetaminophen related liver toxicity. This led to prompt initiation of NAC therapy and prevention of ALF. This case demonstrates the importance of not excluding acetaminophen toxicity because of undetectable levels, especially in patients who use acetaminophen chronically, and initiating NAC therapy early for patients with ALI or ALF when acetaminophen toxicity is suspected.
2218 Recurrent Hepatocellular Carcinoma From Needle Tract Seeding 13 Years Post-Transplant
Authors: Palmer Quinton D. , Perisetti Abhilash , Broadfoot Brannon , Johnson Kemmian D. , Garcia-Saenz-de-Sicilia Mauricio
Published: October 2019

INTRODUCTION:

Liver biopsy (LB) is a known risk factor for tumor seeding and hepatocellular carcinoma (HCC) recurrence. The time from LB to confirmed needle tract seeding (NTS) varies from 3 months to 4 years. We present case of recurrent HCC due to NTS 13 years after LB who presented with a right intercostal wall mass.

CASE DESCRIPTION/METHODS:

A 32-year-old Caucasian male presented to his primary care provider (PCP) in 2004 with recurrent right upper abdominal pain. A CT abdomen & pelvis showed 15 × 12 × 12 cm lesion in the right lobe of the liver with central hypodensity and 1-2 cm solid peripheral rim. His PCP requested CT guided percutaneous needle biopsy. Cytologic analysis was negative for malignant cells. After referral to our institution he underwent posterior right hepatectomy. A 14 × 12 × 7 cm well circumscribed tumor was removed with histopathology confirming well-differentiated HCC with negative margins (Figure 1A). In 2007, new hepatic lesions were noted during HCC surveillance for which he underwent orthotopic liver transplantation (OLT). He continued HCC surveillance which included CT abdomen, pelvis and thorax every 1- and 3-years, whole body bone scintigraphy every 3 years and abdominal US every 6-month intervals; which were negative for HCC recurrence. In 2017 (13 years post OLT), he returned with six months of right intercostal pain and swelling. CT chest & abdomen showed a large mass involving the right 10th rib, soft tissue, and lung nodules (Figure 2). Biopsy of the mass showed well-differentiated HCC, suspicious for vascular invasion (Figures 1B and 3). He was initially started sorafenib however could not tolerate it. He could not receive nivolumab due to risk of rejection and is currently on cabozatinib. He received palliative radiation for pain related to metastasis.

DISCUSSION:

This case highlights NTS from the LB resulting in HCC recurrence and potentially compromising curative therapies such as hepatectomy and OLT. NTC in HCC is rare with a reported incidence from 1 to 5% and could potential implant 1,000 to 100,000 malignant cells along the needle tract. Due to the risk of NTS, percutaneous biopsy is avoided in indeterminate nodules and should be used only in selected cases. Prompt referral to an experienced hepatologist is imperative. LB should be reserved for lesions in which no definitive surgical intervention is planned, and pathological confirmation is necessary for non-surgical therapy.
2230 Benign Intermittent Intestinal Alkaline Phosphatase Elevation
Authors: Mansoor Muhammad Sohail , Tageldin Omar , Parsa Nour , Itani Wafic , Alexandre Cassidy , Ells Peter F.
Published: October 2019

INTRODUCTION:

Liver function tests (LFTs) are commonly checked during routine clinical encounters without specific signs or symptoms. An elevated alkaline phosphatase (AP) level is followed by investigative algorithms to identify the etiology. Total AP comprises liver, bone and intestinal fractions. Elevated intestinal alkaline phosphatase (IAP) can occur as a rare benign condition or due to intestinal pathologies. Unlike previously published reports of benign persistent IAP elevation, our patient had intermittent elevation of IAP.

CASE DESCRIPTION/METHODS:

A 48-year-old obese female was seen in liver clinic for evaluation of elevated AP for the last two years. She had undergone work-up for elevated AP on several occasions but the exact etiology was not found. She did not report any prior history of jaundice, pruritis, nausea, vomiting, diarrhea, abdominal pain, arthralgias or arthritis. She denied any family history of elevated IAP. She was found to have elevated total AP on 6 separate occasions over the last 18 months ranging from 186 to 239 U/l (normal < 117). Her fasting isozyme fractionation was checked 4 times. She had elevated total AP and normal liver/bone fractions on all occasions but twice had elevated IAP of 62 and 93 U/l (normal < 15 U/l), 26-33% of total AP (normal < 14%). Her other LFTs, TFT, PTH, Ca, CBC, BMP, GGT, viral hepatitis serologies, AMA and Vit D were unremarkable. Abdominal imaging revealed a fatty liver while a bone scan was normal. Our patient remained asymptomatic and did not require any treatment.

DISCUSSION:

Elevated AP can be physiological during rapid bone growth and pregnancy or pathological due to hepatobiliary disease or abnormal bone metabolism. Non-hepatic causes of elevated AP include heart failure, renal failure, hyperthyroidism, hyperparathyroidism and certain malignancies. IAP normally accounts for up to 14% of total AP. IAP can be elevated in conditions such as intestinal perforation, intestinal ischemia, extensive erosions/ulceration in GI tract, liver cirrhosis, familial benign elevation of IAP or post-prandial rise after a fatty meal particularly in patients with blood group B or O. Our patient did not have any of the above-listed conditions. Although she was blood group B, the blood draws were done after an overnight fast. While investigating elevated AP clinicians should be aware of pathological and benign causes of IAP elevation including benign intermittent IAP elevation which may require repeated testing of AP isozymes.