bluuebunny/crossref_metadata_2025 huggingface dataset:
2103 Resolution of Infliximab-Induced Palmar Pustular Psoriasis (PPP) After Switching to Biosimilar Infliximab-DYYB
Authors: Abdulla Hafsa , Schairer Jason , Caines Allyce N.
Published: October 2019

INTRODUCTION:

Biosimilars are designed to approximate the effectiveness and safety profile of the reference drugs they are based upon. A person who has a side effect to either the biosimilar or the reference drug would have a similar adverse event to the other medication. Infliximab is an anti-TNF drug used in a variety of autoimmune conditions including UC. While highly effective, it is associated with new onset psoriasis in 5-9% of patients with IBD. That is not typically an indication to abandon the medication if it is otherwise effective. We describe the case of a person with UC on infliximab with the adverse event of PPP who was changed to infliximab-dyyb for financial reasons and had resolution of their skin lesions.

CASE DESCRIPTION/METHODS:

A 68 year old F with history of pancolonic UC was started on Infliximab 5 mg/kg/8 weeks. After 8 months of therapy and due to unresolved inflammation and symptoms, infliximab was increased to 10 mg/kg/8 weeks resulting in clinical remission. She had no prior history of psoriasis or other skin disease but after one year on infliximab she developed a new rash, examination showed well demarcated, pruritic, tender raised erythematous plaques on bilateral palms with salmon colored papules and small pustules (Figures 1 and 2). Dermatology diagnosed her with PPP secondary to infliximab. She was treated for over a year with clobestasol ointment with only modest improvement. Due to infusion center policy, her infliximab was changed to infliximab-dyyb. On 3 month follow up it was noted that the rash had completely resolved since switching to the biosimilar (Figure 3).

DISCUSSION:

Biosimilars of biologic therapies have become increasingly available. They are designed to recreate the effectiveness and safety of the reference medication. While some people develop side effects or loss of response when switching to a biosimilar from a reference medication, adverse events tend to happen at the same rate, suggesting that the event is not due to the biosimilar. Psoriasis caused by anti-TNF is a known adverse reaction. This may be due to a disruption in the balance from TNFα leading to increased production of IFN gamma. In studies infliximab led to psoriasis 5-9% compared to 5-12% in infliximab-dyyb. Even though it is believed that both the reference drug and biosimilar drug have similar efficacy and adverse reaction profiles, we hypothesize that our patient may have developed an immunogenic reaction to a part of the infliximab molecule that is not present in its biosimilar product infliximab-dyyb.
2107 A Case of Crohn’s Disease Complicated With Liver Abscess, Enterohepatic and Enterocutaneous Fistulas
Authors: Ajao Susanne , Lakkasani Saraswathi , Spira Etan , Adib Sami
Published: October 2019

INTRODUCTION:

Crohn’s disease (CD) is a chronic inflammatory disease which can affect any part of the gastrointestinal tract. Liver abscesses and fistulas between a solid organ and intestine are rare. Here we present a unique case report of a CD patient who developed liver abscesses complicated by enterohepatic and enterocutaneous fistula.

CASE DESCRIPTION/METHODS:

48-year-old male with a longstanding history of CD presented with abdominal pain. A CT of the abdomen revealed multifocal hepatic abscesses (Figure 1). The abscesses were initially percutaneously drained and antibiotics were administered. Five weeks following discharge he presented with complains of worsened abdominal pain. He had developed a foul smelling pus-draining wound at site of the drainage. A repeated CT abdomen revealed persistent hepatic abscess with small bubbles of free air adjacent to the inferior hepatic edge with a thin enhancing tract suggesting an early enterohepatic fistula (Figure 2) and an enterocutaneous fistula in the lateral abdominal wall between the bowel and the skin (Figure 3). He underwent a right hemicolectomy with drainage of the hepatic abscesses and repair of the enterocutaneous and enterohepatic fistula. The biopsies from the ileo-cecal region showed extensive ulceration with underling transmural inflammation of mucosa and extensive active inflammation of visceral serosa with reactive fibrosis, suggestive of severe CD. His postoperative recovery was uneventful. Routine colonoscopy evaluation of the ileo-colonic anastomosis two months later showed erythema and inflammation at the anastomosis site with granular inflammation throughout the colon (Figure 4). He is currently doing well on Infliximab and has not reported further complications.

DISCUSSION:

Liver abscess and solid organ to intestinal fistulas are rare complications of CD. The incidence of liver abscess is higher in patients with CD compared with the general population. The diagnosis of liver abscesses is frequently delayed as patients present similar to a CD exacerbation. Unlike the patient in this report, intestinal symptoms may be absent leaving little to no evidence to suggest the presence of a liver abscess on clinical presentation. Imaging including CT scans and ultrasound help to facilitate the diagnosis of this rare condition. In this case, we have shown that surgical intervention, antibiotics and immunotherapy can help with successful outcomes in cases of liver abscesses, enterohepatic and enterocutaneous fistulas.
2110 A Case of IgA Vasculitis in Crohn’s Disease and Recurrent Clostridioides difficile Infection
Authors: Voth Elida , Olson Emily , Raffals Laura E.
Published: October 2019

INTRODUCTION:

IgA vasculitis (IgAV) is an immune-mediated systemic vasculitis characterized by palpable purpura, arthralgias, abdominal pain, and renal disease. Approximately 90% of cases occur in children; however, adults are at increased risk for more severe disease. The pathogenesis of IgAV is associated with inflammatory, infectious, autoimmune, and medication triggers, including tumor necrosis factor (TNF) alpha inhibitors. We describe a case of a man with Crohn’s disease (CD) who developed IgAV in the setting of a perirectal abscess, recurrent Clostridioides difficile infection (CDI), and anti-TNF therapy.

CASE DESCRIPTION/METHODS:

A 20 year old man with ileocolonic Crohn’s disease and perianal involvement, inflammatory arthropathy, and recurrent CDI presented to an outside ED with increased abdominal pain and rash on the extremities, trunk, and soft palate. Medications included etanercept, vedolizumab, and prednisolone. In the ED, the patient was hypotensive and tachycardic. CT abdomen/pelvis noted multifocal active inflammatory disease and a 3.2 cm abscess in the left ischiorectal fossa. He was initiated on broad spectrum antibiotics for septic shock and underwent emergent perirectal drain placement; post-operatively, his shock resolved. He was transferred to our institution for further management. Upon arrival, the patient was hemodynamically stable and remained on broad spectrum antibiotics and high dose prednisolone. Review of systems was notable for worsening abdominal pain and hematuria. Biopsy of the rash demonstrated IgA vasculitis. C. difficile toxin PCR was positive. Repeat urinalysis demonstrated nephrotic range proteinuria and hematuria, consistent with IgA nephropathy. ACE-inhibitor therapy was initiated, and skin lesions gradually improved with topical triamcinolone.

DISCUSSION:

We report a case of a patient with ileocolonic and perianal Crohn’s disease on TNF-alpha inhibitor therapy who developed IgA vasculitis in the setting of septic shock secondary to perirectal abscess and recurrent CDI. This case highlights anti-TNF therapy, infection and inflammatory bowel diseases as potential causes of systemic vasculitis. A high clinical suspicion is needed in order to obtain an early histopathologic diagnosis for IgAV and prompt evaluation of other organ system involvement.
2111 Antibiotic Dependent Pouchitis Successfully Managed With Vedolizumab in a Patient With a Prior History of Renal Malignancy
Authors: Farrakhan Kanhai , Fine Sean
Published: October 2019

INTRODUCTION:

Pouchitis is a known complication of ileal pouch-anal anastomosis (IPAA). The mechanism is unknown but is felt to be due to altered bacterial flora and then a dysregulated immune response in the pouch. Although one of the mainstays of treatment is antibiotics, long-term use for patients with chronic pouchitis (CP) may not be addressing the underlying mechanism while also subjecting the patient to the risk of prolonged antibiotics. New limited data supports the use of biologics in the management of CP. We report a case of a man with a history of chronic antibiotic dependent pouchitis (CADP) and prior malignancy who was successfully managed with vedolizumab.

CASE DESCRIPTION/METHODS:

44 year-old male with past medical history of ulcerative colitis status-post IPAA, renal oncytoma status-post resection (2017), non-insulin dependent diabetes, and fatty liver disease presented with persistently increased bowel movements. He endorsed weeks of twenty bowel movements per day to the point that he was awoken from sleep. He presented to urgent care where he was started on ciprofloxacin and metronidazole yet he continued to be symptomatic. He then presented to gastroenterology clinic and was started on xifaxin. He subsequently underwent a pouchoscopy showing CP (confirmed by biopsy). After some discussion, the plan was to initiate a biologic as he was refractory to antibiotics. However he was concerned about starting systemic immunosuppression given his prior malignancy. As he was post resection with reported cure and no plan to undergo further treatment, he was started on vedolizumab. On vedolizumab he endorsed resolution of symptoms with a dramatic improvement in quality of life.

DISCUSSION:

The challenge in management of CP arises when there is dependence on antibiotics and continued symptoms. Recent studies support the use of biologics (i.e. vedolizumab). These papers document resolution of symptoms and endoscopic improvement of disease. However there has yet to be robust data evaluating the efficacy or safety of biologics for this indication in those with prior malignancy. In this case there was initial hesitation but given the remote nature and clinical stability of the malignancy as well as gut-specificity of vedolizumab the decision was made to pursue therapy. This case highlights the successful use of vedolizumab for the treatment of CADP. The use of biologics in CP needs to further be studied, especially in a cost-benefit analysis looking further into outcomes related to long-term antibiotic use.
2113 Biofeedback Therapy With the Rao Protocol for Dyssynergic Defecation Is Effective Among Patients With Inflammatory Bowel Disease
Authors: Spilman Samantha , Dulai Parambir , Kunkel David
Published: October 2019

INTRODUCTION:

Dyssynergic defecation (DD) symptoms are common in patients with inflammatory bowel disease (IBD). Biofeedback (BFB) is a standard of care treatment for DD, however, few studies have evaluated its efficacy in IBD patients with DD.

CASE DESCRIPTION/METHODS:

This is a case series that looks at 5 patients with IBD who were enrolled in BFB for DD between 2015 to 2018 at a tertiary referral motility program. All patients had greater than two sessions, survey and high resolution anorectal manometry (HR-ARM) data were collected at baseline and during each DD BFB visit. The Rao protocol for BFB is a physician-led program that consists of an active phase with the number of sessions tailored to each patient’s progress, followed by refresher sessions. A solid state HR-ARM catheter is utilized with sensors in the rectum/pouch and anal canal. Stool retention simulation consists of inflation of a rectal balloon during manometry based BFB. A total of 5 patients were identified for this case series. The average age of the patients was 46 years. Of these 5 patients, 3 had Crohn’s disease and 2 had ulcerative colitis. After completion of BFB, IBD patients experienced a significant improvement in stool form (Bristol stool scale type 2 to 6, P = 0.01), rise in the defecation index (intrarectal/pouch pressure divided by intra-anal pressure during simulated defecation; 0.39 to 0.81, P = 0.04), and complete resolution of DD with a rectal balloon inflated to simulate stool present in the rectum/pouch on final BFB session (P < 0.01). IBD patients did not report a significant improvement in global bowel satisfaction rating on a 10-point Likert scale (2.2 to 3.6, P = 0.22).

DISCUSSION:

Biofeedback with the Rao protocol in conjunction with use of HR-ARM catheters shows efficacy in the correction of dyssynergia pattern, leading to improvement in objective measures such as defecation index and stool form on diary in IBD patients. Subjective improvement in global bowel satisfaction rating was less than the non-IBD cohort. In conclusion, patients with IBD who are found to have DD should be given consideration for enrollment in a BFB program, which is a labor-intensive approach but has no adverse effects.
2114 Pharyngo-esophageal Perforation During Endoscopic Ultrasound: Case Report and Literature Review
Authors: Tariq Raseen , Enslin Sarah , Kaul Vivek
Published: October 2019

INTRODUCTION:

EUS related serious complications such as luminal perforation, pancreatitis and bleeding are rare. We report a case of EUS-related pharyngo-esophageal perforation, successfully managed conservatively and brief literature review.

CASE DESCRIPTION/METHODS:

A 75-year-old male presented with elevated LFTs without jaundice. CA 19-9 was elevated (112 U/mL). CT revealed a double duct sign and a 3 cm pancreatic head mass (Figure 1). Decision was made to proceed with EUS with FNA. Diagnostic EGD noted no luminal esophageal narrowing. The linear array echoendoscope was inserted into the oropharynx but was difficult to pass into the esophagus secondary to cervical osteophytes. The gastroscope was reinserted into the esophagus. Minimal pharyngeal mucosal trauma was noted. A savary guidewire was passed into the stomach; the gastroscope was removed. The echoendoscope was backloaded onto the wire and reinsertion attempted. Despite gentle maneuvers and multiple attempts, resistance to passage was encountered, esophageal intubation was not possible; the echoendoscope was removed. Repeat EGD revealed a 2 cm deep mucosal tear extending from the posterior pharynx to the esophageal inlet without full-thickness perforation or significant bleeding (Figure 2). The gastroscope and the guidewire were removed and the procedure was terminated. Patient complained of throat pain, especially with swallows. CT showed pneumomediastinum and extraluminal air and edema adjacent to the right aspect of the pharynx & esophagus (Figure 3), consistent with a pharyngo-esophageal microperforation. Thoracic surgery was consulted, antibiotics started, patient kept NPO. The patient remained hemodynamically stable with improved pain and no need for surgical intervention, discharged home on post-procedure day 4.

DISCUSSION:

EUS is a safe procedure with complication rates comparable to EGD. The rate of esophageal perforation is very low, ranging from 0.03-0.04%. The treatment for pharyngo-esophageal perforation depends upon the degree, location, timing of diagnosis, hemodynamic status and clinical status of the patient. In a case series of 16 cervical esophageal perforations, 44% of patients had history of difficult intubation with endoscopic procedures. 81% were managed conservatively.1 Early recognition and timely management is critical for ensuring an excellent outcome with conservative management.

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2116 Salvage Therapy for Recurrent Gastrojejunal Anastomotic Stricture Using a Lumen-Apposing Metal Stent
Authors: Oldfield Edward C. , Parekh Parth J.
Published: October 2019

INTRODUCTION:

Gastrojejunal (GJ) anastomotic stricture following Roux-en-Y gastric bypass is a well-known complication of the surgery with reported ranges varying from 2.9-23%.1 Unfortunately, prior endoscopic interventions for these strictures have had limited durability of treatment response.

CASE DESCRIPTION/METHODS:

A 71-year-old male with previous Roux-en-Y gastric bypass presented to our hospital with 2 weeks of nausea, vomiting, weight loss, and severe hypoglycemia. Initial imaging with CT abdomen showed a fluid-filled and distended gastric pouch with likely stenosis of the GJ anastomosis. An upper GI series was performed which confirmed significant stenosis at the GJ anastomosis (Figure 1a). An EGD was performed at which time the stricture was successfully dilated using a through-the-scope (TTS) 6-7-8 mm and then an 8-9-10 mm balloon dilator (Figure 2). Unfortunately, the patient did not clinically respond to dilation and was unable to advance diet beyond liquids, requiring initiation of total parenteral nutrition. Subsequently, the patient underwent a repeat EGD with placement of a 20 mm × 10 mm lumen apposing metal stent (LAMS) (Axios, Boston Scientific) under fluoroscopic guidance. The stent was successfully dilated with a TTS 12-13.5-15 mm balloon dilator to a maximal size of 13.5 mm with obliteration of the waist. The LAMS was then sutured into place with the endoscopic suturing device (OverStitch, Apollo Endosurgery, Inc) using 2.0 polypropylene suture and placing 2 interrupted sutures with cinches on both ends (Figure 3). An upper GI series was repeated 24 hours after LAMS, which showed excellent functioning of the stent without leak or obstruction (Figure 1b). Over the next five days, the patient’s symptoms abated, diet was gradually advanced to low residue diet, TPN was discontinued, and the patient was discharged home.

DISCUSSION:

Management of these strictures has primarily been pneumatic balloon dilation or fully covered self-expanding stents; however, dilation is unlikely to achieve durable response and other stents are associated with complications of stent migration and recurrence of symptoms after removal. Previous case reports have documented successful treatment of GJ anastomotic strictures using LAMS with excellent response given its novel shape and anchoring phalanges.
1
We further show the successful endoscopic suturing of the LAMS, which will allow for prolonged time for stent placement with enhanced risk-mitigation for stent migration.
2121 A Combined Antegrade/retrograde Dilation Procedure With Gastroenterology and Interventional Radiology: A Case Report
Authors: Chaudhari Rahul B. , Attalla Sarah , Schwartz Stephen
Published: October 2019

INTRODUCTION:

Endoscopic recanalization techniques for complete esophageal obstructions are not very well established. Dilatations of esophageal strictures causing complete obstruction by conventional bougienage techniques are not very successful. We present a case where complete esophageal stricture was treated with endoscopic recanalization by combine efforts of GI and IR team with endoscopy and guidewire by IR.

CASE DESCRIPTION/METHODS:

A 78-year-old male with a past medical history of HTN, HLD, DVT, prostate cancer, esophageal cancer s/p esophagectomy with gastric pull-up c/b anastomotic stricture s/p esophageal stent placement s/p removal in 1/2019 c/b recurrent stricture progressing to apparently complete obstruction. He had gastrostomy tube placed by interventional radiology. During endoscopy, one severe stenosis was found at the esophageal anastomosis with surrounding staples. A lumen was not visualized and Gentle probing using a Savary guidewire, fluoroscopic guidance or a Glot tip catheter did not help to visualize the lumen. Patient had a J tube which precludes retrograde approach. Procedure was aborted. Subsequently with IR guidance, a catheter with a metal wire was passed in retrograde fashion from gastrostomy site to the stenosed lumen. A puncture was carefully made and a guidewire was advanced out the mouth. Site of recanalization was dilated to 6 mm. Using the guidewire, an 18 mm × 10.3 cm WallFlex fully covered stent was loaded over it and passed into the esophagus. The stent was then deployed. Patient improved clinically. Subsequent Endoscopy showed mild tissue hyperplasia just proximal to the stent. Patient was followed up closely and still needed regular endoscopies and dilatations but is clinically stable and his dysphagia and quality of life has improved significantly.

DISCUSSION:

Patients with advanced malignancy and limited life expectancy who develop complete esophageal stricture and cannot tolerate surgical reconstruction benefit significantly from the endoscopic recanalization. New endoscopic techniques include rendezvous recanalization and CARD(combined antegrade‐retrograde dilation). In our case, combined efforts of GI and Interventional radiology helped to recanalize the complete obstruction of the esophagus by GI guided endoscopy and IR guided guidewire. Such novel techniques bring a significant improvement in the overall quality of life of patients with terminal diseases and high surgical risk.
2123 The Vanishing Gastrojejunostomy: A Case Report
Authors: Phan Ethan , Patel Pratik , Gollol Raju Narasimha Swamy , Mudireddy Prashant
Published: October 2019

INTRODUCTION:

Gastrojejunal anastomotic strictures or stenoses are well recognized complications from Roux-en-Y gastric bypass surgery. Endoscopy remains an effective and safe means to diagnose these complications, which can occur as early as one month after surgery. The two main treatment modalities include endoscopy, either with balloon or bouginage dilators, or open versus laparoscopic surgery. Despite direct visualization, endoscopy could easily miss a severely stenotic anastomosis, as illustrated in the case of our a patient with gastrojejunal stenosis status post gastric bypass surgery.

CASE DESCRIPTION/METHODS:

43-year-old man with past medical history of morbid obesity s/p laparoscopic Roux-en-Y was admitted for acute nausea and vomiting. The Rouz-en-Y was performed one month ago and he initially was doing well with expected weight loss. Over the last 10 days, he had persistent nausea, vomiting, and anorexia. Labs were unremarkable at presentation. Initially, the surgical team was consulted and performed an EGD which revealed severe stenosis at the gastrojejunal anastomosis site; a balloon dilator was not able to be passed through the stenosis. The following day, gastroenterology team performed a repeat EGD, which revealed a large hematoma in the gastric body and epinephrine was injected. Initially, the gastrojejunal anastomosis was not clearly visualized despite partial dislodgement of the clot. However, under fluoroscopy, a closed, possible anastomotic site was identified and a wire was advanced through with contrast injection for verification that the wire was in fact in the bowel lumen. The anastomosis was then dilated and an AXIOS stent was placed across the anastomosis. The patient recovered well post-operatively, tolerating PO intake and was discharged. At follow up, the stent was successfully removed via rat-toothed forceps without complication. The anastomotic site was friable, but was wide open and a standard gastroscope was easily advanced through without complications.

DISCUSSION:

Gastrojejunal anastomotic stenosis is a known complication of Roux-en-Y gastric bypass surgeries. Its etiology is not completely understood and likely multifactorial but treatment options include endoscopic dilation and surgery. For our patient, fluoroscopic guidance with wire placement through the anastomotic site was required for successful deployment of the AXIOS stent. Therefore, endoscopic diagnosis should be considered as a safe modality for diagnosis and intervention for these complications.
2129 Lumen-Apposing Metal Stent for Benign Gastric Outlet Obstruction!
Authors: Alsheikh Mira , Kamar Khalil , Haddad Fady , Andrawes Sherif
Published: October 2019

INTRODUCTION:

Lumen-apposing metal stent (LAMS) placement via endoscopic ultrasound (EUS)-guided gastroenterostomy has recently emerged as a promising technique for the management of malignant gastric outlet obstruction (GOO). This is safe, effective and technically feasible if performed by trained advanced endoscopists. Despite that LAMS use in malignant GOO is well defined, it is rarely performed for benign etiologies of GOO and only 4 cases have been reported in the literature. We report the case of a patient with GOO secondary to benign duodenal stricture that was successfully managed by LAMS placement.

CASE DESCRIPTION/METHODS:

A 60-year-old man with history of recurrent duodenal ulcers presented for vomiting and food intolerance for few days. Two years ago he had a GOO secondary to his ulcer disease and was managed by surgical gastrojejunostomy (GJ). A subsequent marginal ulcer perforation required resection of the GJ with small bowel anastomosis and insertion of a GJ tube. Upon presentation, physical examination was notable for epigastric tenderness with no rebound or rigidity. Contrast computed tomography (CT) scan of the abdomen showed a markedly distended stomach and proximal duodenum with focal narrowing near the pancreatic head (Figure 1). Enteric contrast reached the rectum indicating the absence of complete obstruction. Upper endoscopy showed retained solid material in stomach and an almost completely occluded “pin hole” duodenal lumen that could not be traversed with the endoscope. A wire-guided through the scope dilation with a balloon was performed in conjunction with fluoroscopy but was unsuccessful (Figure 2) so a 10 mm × 15 mm EUS-guided LAMS was successfully deployed. Patient’s symptoms resolved and he was able to tolerate diet.

DISCUSSION:

GOO usually occurs secondary to malignancy-related mass effect or luminal invasion. Less commonly GOO can be attributed to benign etiologies namely ulcers, caustic ingestion and inflammation. Often managed by endoscopic balloon dilation, benign strictures can recur. Other less favored options include self-expandable metal stents which use is limited by a high rate of migration and failure and surgical approach which provides definitive treatment but is associated with a high risk of mortality and morbidity. LAMS is a novel and appealing less invasive approach proven to be a safe alternative allowing early restoration of enteral luminal access with good short term success and satisfying safety profile. Further studies and long term follow up are recommended.
2130 Future of Endoscopy: Hybrid Argon Plasma Coagulation for Treatment of Intestinal Metaplasia of the Stomach
Authors: Estifan Elias , Mohamed Abdalla , Cavanagh Yana , Grossman Matthew
Published: October 2019

INTRODUCTION:

Hybrid Argon Plasma Coagulation (Hybrid APC) is an advancement on standard APC technology; application of APC is preceded by high pressure needleless submucosal injection, with the same catheter. APC is indicated for the ablation of benign and dysplastic mucosal lesions such as vascular malformations and Barrett’s mucosa. Hybrid APC offers an advantage over efficacy and safety advantages over standard APC. The submucosal injection acts as a heat sink and disperses excess energy to ensure that the underlying layers (i.e.: muscularis propria) are unaffected. Only the mucosal layer is coagulated, in its entirety.

CASE DESCRIPTION/METHODS:

An 81 years-old Hispanic Male was found to have a 1.2 cm mucosal nodule along the incisura of the stomach (Figure 1). He underwent endoscopic ultrasound (EUS) of the lesion, which confirmed the presence of an isolated gastric nodule with no deep invasion of the muscularis propria, consistent with a T1N0Mx endoscopic staging. He subsequently underwent endoscopic submucosal dissection (ESD) of the lesion. Pathology of the specimen revealed multifocal high-grade dysplasia, arising in the background of extensive intestinal metaplasia. The deep margin was clear; however, the lateral resection margins showed focal involvement of intestinal metaplasia with low-grade dysplasia. In light of the diffuse mucosal dysplasia, the patient was successfully treated with widespread Hybrid APC of the residual intestinal metaplasia (Figures 2 and 3).

DISCUSSION:

Hybrid APC is an effective and efficient treatment modality for mucosal lesions. In one series of 50 patients; 96% achieved complete macroscopic remission of Barrett’s mucosa after a median of 3.5 APC sessions and 85% achieved complete histological remission. Hybrid APC is a promising technology as thermal injury depth is targeted and reduces deep injury as well as subsequent complications when it compared with Standard APC. Applications of hybrid APC will likely continue to grow as this modality is adopted into common parlance. This case is the first to describe the use of Hybrid APC for definitive treatment of intestinal metaplasia.
2133 Hybrid Argon Plasma Coagulation Therapy for Early Esophageal Squamous Cell Carcinoma
Authors: Estifan Elias , Cavanagh Yana , Grossman Matthew
Published: October 2019

INTRODUCTION:

Squamous cell carcinoma is common in Asia, accounting for most cases of esophageal cancer throughout the world, whereas adenocarcinoma is more common in the Western world. Overall, neoplasms of the esophagus carry a poor prognosis. Treatment options depend on the stage of the disease. Endoscopic therapy may be considered for early disease as endoscopic resection is a safe and minimally invasive treatment option for Tis and T1a esophageal malignancies. Esophagectomy is necessary for invasive disease.

CASE DESCRIPTION/METHODS:

A 56 years-old male was found to have non-circumferential mucosal irregularities between 25-27 cm from the incisors (Figure 1). Biopsy of the irregular mucosa revealed atypical squamous proliferation, consistent with squamous cell carcinoma in-situ (Tis). Subsequent endoscopic ultrasound (EUS) evaluation revealed thickened mucosa without the involvement of the deep mucosa or muscularis propria. Endoscopic mucosal resection (EMR) was performed and pathology confirmed clear margins. Subsequent surveillance EGD revealed the persistence of atypical squamous mucosa however extensive post-EMR scarring prevented repeat mucosal resection. The patient refused surgical intervention and the decision was made to pursue hybrid APC ablation of the remaining esophageal mucosa. The esophageal mucosa was lavaged with Lugoll’s Iodine to expose the affected squamous epithelium. The affected areas were then lifted with a solution of saline and methylene blue and ablated using argon plasma coagulation at 50 W (Figure 2).

DISCUSSION:

APC has been successfully used in similar applications; to ablate tissue margins after endoscopic resection of early neoplasia. The development of hybrid APC and its inherent improved safety profile allows for an extension of its application to include primary treatment of dysplastic and neoplastic lesions. In one recent study, tissue damage was limited to the submucosal layer regardless of application time. This case describes an effective novel use of Hybrid APC for treatment of Tis esophageal squamous cell carcinoma.
2134 Drainage of a Mediastinal Abscess After Esophagectomy Using a Lumen-Apposing Metal Stent
Authors: Elfanagely Yousef , Shahid Haroon , Kahaleh Michel , Sarkar Avik , Tyberg Amy
Published: October 2019

INTRODUCTION:

Endoscopic ultrasound (EUS) is an important diagnostic and therapeutic modality in the field of gastrointestinal endoscopy1. Therapeutic EUS has found a role in management of pancreatic fluid collections, biliary and pancreatic duct drainage, and drainage of mediastinal and intra-abdominal abscesses and collections1. We present a case of a mediastinal abscess drainage after esophagectomy using a Lumen-apposing metal. To our knowledge, this is the second case using a Lumen-apposing metal stent for mediastinal collections2.

CASE DESCRIPTION/METHODS:

Case Summary: This is a case of a 75-year-old man with esophageal adenocarcinoma s/p transhiatal esophagectomy complicated by recurrent pleural effusions, ischemic colitis requiring right hemicolectomy and end ileostomy who presented to the ED from rehab because of abnormal lab findings of hypernatremia and leukocytosis. During his hospital stay, the patient developed persistent fevers and leukocytosis. A CT scan of the chest revealed a large posterior mediastinal collection adjacent to the gastric pull-through that coursed inferiorly into the peritoneum. The collection measured 8 cm × 4.1 cm x 12 cm in size and was presumed to be the source of infection. The case was discussed amongst the surgical oncologist, thoracic surgeon, interventional radiologist, and advanced endoscopists. Options for drainage included repeat surgery, percutaneous drain placement, and endoscopic drainage. The consensus opinion was to drain the collection internally by endoscopic ultrasound. The patient underwent a successful EUS-guided abscess drainage with a lumen apposing metal stent. The patient drastically improved after internal drainage with the lumen apposing metal stent. Fevers and leukocystosis resolved. Follow-up CT scan of the chest 10 days later demonstrated a resolution of the mediastinal collection.

DISCUSSION:

Conclusion: Although developed for drainage of pancreatic fluid collections, this case demonstrates that lumen apposing metal stents can be safely used to drain mediastinal collections. Our literature review identified one other case that utilized a lumen-apposing metal stent to drain a mediastinal abscess2. This stent seems to be useful and safe for mediastinal drainage. We recommend a multidisciplinary discussion with surgeons and radiologists when dealing with large mediastinal collections that require drainage.
2135 A Rare Case of Dysphagia From a Cricopharyngeal Septal Cyst Within a Zenker’s Diverticulum Treated With EUS-FNA and Endoscopic Incisional Therapy
Authors: Al-Salameh Nizar , Khalid Ammara , Basi Puneet , Khara Harshit S.
Published: October 2019

INTRODUCTION:

Zenker’s diverticulum (ZD) occurs mostly in elderly patients and may manifest with dysphagia, halitosis, regurgitation, and aspiration. We present a rare cause of esophageal dysphagia from an obstructing cyst on the cricopharyngeal septum within the Zenker’s diverticulum, successfully treated with endoscopic ultrasound guided drainage and endoscopic incisional therapy.

CASE DESCRIPTION/METHODS:

A 68-year-old female was referred for endoscopic treatment of a suspected Zenker’s diverticulum seen on esophagram. On endoscopic exam, she was found to have an obstructing Zenker’s diverticulum in the proximal esophagus with a cystic structure on the cricopharyngeal septum (image 1). Endoscopic ultrasound exam was done to characterize the cystic lesion which showed a 14 mm anechoic round cyst originating in the deep mucosa (image 2). Color Doppler did not find any significant vascular flow within the cyst, which was then aspirated under EUS guidance and cytology confirmed a benign cyst. After cyst decompression, the Zenker’s diverticulum was successfully treated using flexible endoscopic incisional therapy with the SB knife (image 3). Patient had complete resolution of her dysphagia with no symptom recurrence.

DISCUSSION:

Zenker’s diverticulum has been successfully treated with surgical and endoscopic techniques, but the presence of incidental cystic or vascular lesions highlight the need for endoscopic evaluation and use of adjunct tools such as endoscopic ultrasound to rule out vascular flow and assist in drainage before endoscopic therapy can be pursued. We report a unique case of cricopharyngeal septal cyst as the cause of symptomatic dysphagia within a Zenker’s diverticulum which was successfully treated with endoscopic interventional tools.
2137 The Game Changing Utility of EUS-FNA for Pancreatic Evaluation: Not All Pancreas Masses on CT Are Pancreas Tumors!
Authors: Park Steven , Perez-Colon Anjanet , Foor-Pessin Caitlin , Kothari Truptesh , Fultz Patrick J. , Galka Eva , Kaul Vivek , Kothari Shivangi
Published: October 2019

INTRODUCTION:

A pancreatic mass seen on cross-sectional imaging with liver lesions or lymphadenopathy is concerning for a pancreatic malignancy. Previous reports have discussed the utility of EUS-FNA for evaluation of pancreatic masses; this case series aims to reinforce the game-changing utility of EUS-FNA for the clarification of suspected pancreatic neoplasia.

CASE DESCRIPTION/METHODS:

Case #1: A 68-year-old woman undergoing evaluation for hematuria was found to have two enhancing liver lesions, two pulmonary nodules, and a low attenuation zone in the uncinate process of the pancreas on CT (Image 1). Physical exam and laboratory tests were unremarkable. A pancreas protocol CT at our center confirmed the above findings and the patient was referred for EUS-FNA. On EUS, pancreatic anatomy was completely normal and no mass was identified. Subsequent evaluation with a triphasic MRI (Image 2) concluded that the liver lesions were atypical hemangiomas and the pancreas had focal fatty replacement that can mimic a pancreatic tumor. A repeat EUS at 6 months was unremarkable and the patient is doing well. Case #2: A 56-year-old woman with history of melanoma presented with RUQ pain and +30lbs weight loss over the previous 5 months. Physical examination was unremarkable and laboratory tests were notable for elevated LFTs. CT (Image 3) revealed a homogeneously enhancing retroperitoneal mass arising between the pancreatic uncinate and D3 with several enlarged mesenteric lymph nodes, suspected to be pancreatic neoplasm. Further evaluation with EUS revealed a 3.5 cm heterogenous periduodenal mass abutting D2 and enlarged peri-gastric lymph nodes. FNA was performed and histopathology identified the mass as gastrointestinal stromal tumor (GIST) with reactive lymph nodes. The patient was started on neoadjuvant Imatinib with approximately 25% shrinkage of the mass appreciated in the first 2 months. Afterward, the patient underwent pancreaticoduodenectomy and surgical pathology revealed a mixed subtype duodenal GIST with a low mitotic rate.

DISCUSSION:

We report 2 cases of suspected metastatic pancreatic carcinoma whose diagnoses were elucidated as focal fatty replacement and duodenal GIST, respectively, with the help of EUS +/- FNA. Pancreatic lesions found on cross-sectional imaging that are thought to be primary pancreatic neoplasms should be further evaluated by EUS. EUS with/without FNA can be a game-changing imaging modality in such cases, providing an accurate diagnosis and helping guide appropriate management.
2139 Endoscopic Closure of Post-Operative Duodenal-Enteric Fistula Following Repair of Abdominal Gunshot Wounds
Authors: Kruchko David H. , Shah Natasha , Hoff Ryan T. , Lakha Asif
Published: October 2019

INTRODUCTION:

Gastrointestinal defects including enteric duodenal fistulas cause complications such as infection and multiorgan failure, which may lead to death. The gold standard is surgical closure; however, this requires repeat surgeries and may lead to post-operative complications. The over the scope clip (OTSC) is known to be an effective and safe modality for GI defects such as perforation and GI tract leaks, but studies have shown limited success for closure of gastrointestinal fistulous tracts and is dependent on the anatomical location and size of the defect. We report a case where an OTSC was used successfully for immediate closure of a duodenal-enteric fistula caused by a gunshot wound, which saved the patient from undergoing additional surgery.

CASE DESCRIPTION/METHODS:

A 41-year-old man presented with multiple gunshot wounds to the abdomen. An emergent exploratory laparotomy was performed, with partial small bowel resection for gunshot wounds to the jejunum and ileum. His post-operative course was complicated by an intra-abdominal abscess. A sinogram revealed a duodenal-enteric fistula with a fluid collection, requiring Jackson Pratt drain placement and antibiotic therapy (A). Given the lack of improvement, the patient was taken for esophagogastroduodenoscopy (EGD). A 10 mm fistulous tract was identified at the junction of the 2nd and 3rd portion of the duodenum (B). A 12/6t OTSC was deployed over a pediatric colonoscope. The scope was passed to the level of the fistula, with fluoroscopy for localization. Using suction, the fistula was pulled into the cap of the OTSC device and the clip was successfully deployed, closing the fistula (C). Clip placement was confirmed via fluoroscopy. The next day, upper gastrointestinal stomach X-Ray was completed and did not show extravasation to suggest a leak at the duodenum. His diet was advanced and after a prolonged hospital course, he was discharged.

DISCUSSION:

This case highlights the use of OTSC for a fistula caused by trauma rather than common causes such as bariatric surgery, percutaneous gastrostomy tube placement, or an underlying malignancy. Although technically challenging, when used as primary therapy, OTSC closure of an enteric fistulous tract has the potential to reduce the need for an emergent surgery. Therefore, OTSC closure should be considered an effective therapeutic modality in patients with trauma-related abdominal enteric fistulas.
2146 Combined Novel Endoscopic Techniques in Esophageal Carcinoma Management
Authors: Ali Osman , Khan Imran , Kim Raymond E.
Published: October 2019

INTRODUCTION:

A variety of techniques are currently being investigated to provide optimal resection of submucosal tumors by endoscopy. Specifically, peroral endoscopic myotomy (POEM) is a form of natural orifice transluminal endoscopic procedure which was originally established as a minimally invasive technique to treat achalasia and esophageal motility disorders. Due to its success in treatment of esophageal motility disorders, certain Centers of Excellence for advanced endoscopy have expanded the use of POEM in combination with other advanced endoscopic techniques for treating esophageal cancers. In this case, we present a 69-year-old male with squamous cell cancer (SCC) in the lower third of the esophagus who was successfully treated using combined endoscopic submucosal dissection (ESD), submucosal tunneling, and POEM techniques.

CASE DESCRIPTION/METHODS:

A 69-year-old male with a medical history of 50-pack-year tobacco abuse, chronic alcohol use, and chronic pancreatitis was initially evaluated with EGD and EUS for anorexia, weight loss, and pancreatic cysts. Initial EGD required biopsies of nodular esophageal mucosa revealing underlying squamous cell carcinoma in situ. Repeat endoscopy 2 months later revealed a large tumor circumferentially involving 80% of the lumen in the lower esophagus. Subsequently, the patient received therapeutic intervention combining ESD and POEM techniques for tumor resection, prognostication, and symptom relief. Lesion borders were marked, and a circumferential incision was made around the lesion lifting it from the muscularis propria allowing for successfully mass excision. The submucosal dissection combined with circumferential tunneling technique allowed for complete resection of the tumor. The patient reported post-procedure symptomatic relief and was able to resume oral intake.

DISCUSSION:

POEM is a combination of the pre-existing endoscopic myotomy procedures in conjunction with endoscopic submucosal tunneling techniques. Although POEM is labor intensive, its application gives precision by granting access to the neoplasms without affecting deeper esophageal layers. This promising advance in gastrointestinal procedures compared to esophagectomy has shown in reported studies to offer a lower morbidity rate while providing similar cancer-free survival. Our case demonstrates successful treatment using POEM and adjunct endoscopic therapies in submucosal tunneling and submucosal tunneling endoscopic resection (STER) in the treatment of large circumferential esophageal cancer.
2150 Successful Endoscopic Closure of a Pyeloduodenal Fistula Using the Over-the-Scope Clip System
Authors: Duh Erica , Clary Meredith , Samarasena Jason , Clayman Ralph , Chang Kenneth J.
Published: October 2019

INTRODUCTION:

Approximately 100 cases of pyeloduodenal fistula (PDF) have been reported in the literature. PDF most often results from pyelonephritis due to nephrolithiasis, when inflammation extends to the duodenum given its relative immobility and lack of posterior peritoneal covering. Diagnosis of a PDF is usually made with computed tomography (CT) of the abdomen with contrast. The mainstay of therapy for PDF is nephrectomy and primary closure of the duodenum. We are presenting the second documented case of endoscopic closure of a PDF using the over-the-scope clip (OTSC) system and the third case of endoscopically treated PDF. This method provides an alternative to open surgery.

CASE DESCRIPTION/METHODS:

A 62 year old female presented with sharp, severe abdominal pain. She denied back pain, hematuria, fever, and dysuria. She had no significant past medical history and did not take any medications. CT abdomen and pelvis demonstrated a large right-sided staghorn calculus extending into the renal pelvis. The patient underwent percutaneous nephrolithotomy, which was complicated by perforation of the renal pelvis and abdominal compartment syndrome. Subsequently, a proximal ureteral stricture was refractory to stenting and balloon dilation. CT urography demonstrated a PDF (Image 1). After placement of a metallic ureteral stent and nephrostomy tube, a nephrostogram was negative for extravasation, so the patient underwent EGD to evaluate for the resolution of the PDF. During the procedure, iohexol contrast and methylene blue were inserted via nephrostomy tube, and fluoroscopic imaging showed contrast in the right kidney and bladder without extravasation. However, on endoscopy, methylene blue extravasation led to identification of two mucosal defects in the anterior duodenal sweep (Image 2). The larger defect was closed using the helix tissue retractor and OTSC system (12/6 t-type) (Image 3). The smaller defect was closed with 2 hemostasis clips. Follow-up renal scan and CT imaging showed no evidence of contrast extravasation.

DISCUSSION:

The OTSC is an innovative endoscopic technique most often used for hemostasis and for treatment of endoscopic or surgical complications (e.g., fistula, leakage, or perforation). Most reports document successful OTSC use for fistula closure including gastrocutaneous and esophageal fistulas. Our case is, to our knowledge, the second ever documented PDF closure using the OTSC system.