bluuebunny/crossref_metadata_2025 huggingface dataset:
2060 Sclerosing Mesenteritis Treated Successfully With Ustekinumab: An Off-Label Use of Infliximab and Ustekinumab
Authors: Byriel Ben , Walker Megan J. , Fischer Monika
Published: October 2019

INTRODUCTION:

Sclerosing Mesenteritis is a rare, non-neoplastic, inflammatory condition that affects the mesentery. It typically presents with a variety of gastrointestinal symptoms such as abdominal pain, nausea, vomiting, and diarrhea, but is largely variable. It is often treated successfully with steroids, estrogen modulators, anti-purine metabolites, and other antineoplastic agents. However, due to the wide ranging side-effect profiles of these medications, treatment limitations can arise when these options are exhausted. This case is particularly interesting considering the depth of the treatment algorithm pursued, and the potential change in management of sclerosing mesenteritis for future patients.

CASE DESCRIPTION/METHODS:

A 45-year-old male presented with intermittent left upper quadrant pain with associated nausea, vomiting, and diarrhea. CT scan of the abdomen revealed diffuse central mesenteric stranding and lymphadenopathy. Histopathology of the mesentery revealed fatty necrosis and foamy histiocytes, consistent with a diagnosis of sclerosing mesenteritis. Over the course of years, the patient was treated with prednisone, azathioprine, colchicine, cyclophosphamide, and methotrexate, but had persistent symptoms and intolerable medication side effects. He was started on infliximab, enabling him to decrease his prednisone dose to 12.5 milligrams daily and had symptom free remission. Six months later, he developed mesenteric large B cell lymphoma and infliximab had to be discontinued. The patient went into remission after R-CHOP chemotherapy. Due to chronic prednisone use, he had developed osteoporosis, bilateral cataracts, and diabetes mellitus type 2. Faced with a lack of other pharmacologic options and concern for continued glucocorticoid usage, an off-label use of ustekinumab was pursued. The patient was induced with a 520 milligram dose IV and continued on 90 milligram dose SQ every 8 weeks, leading to complete resolution of his symptoms. The patient was able to be weaned to 10 mg of prednisone daily, his lowest in 15 years, and is continuing to wean the prednisone with help of endocrinology.

DISCUSSION:

This case highlights successful utilization of infliximab and ustekinumab for steroid-dependent sclerosing mesenteritis. It may implicate the role of TNF-alpha and interleukins 12, 23 in the pathogenesis of the disease, and suggests alternative treatments to traditional pharmacologic therapy are available.
2065 A Rare Case of IgA Vasculitis Secondary to Infliximab Use in Crohn’s Disease
Authors: Vangimalla Shiva , Mirza Muhammad U. , Choden Tenzin , Malhotra Nidhi
Published: October 2019

INTRODUCTION:

The advent of Infliximab (IFX) has revolutionized the treatment for inflammatory bowel disease. Although the most common adverse effects include infusion site reactions and loss of response due to antibody formation, there have been some reports of secondary autoimmune conditions. Herein, we report a rare case of IgA vasculitis likely as a result of IFX therapy.

CASE DESCRIPTION/METHODS:

A 53-year-old female with known fistulizing ileocolonic Crohn's disease (CD) on IFX since 2002, multiple bowel surgeries for her CD, rheumatoid arthritis, and postoperative deep vein thrombosis, presented with a 2-week history of progressive petechial rash on her bilateral lower extremities (Figures 1 and 2). Skin biopsy of one of the lesions was notable for granular deposition of IgA consistent with IgA vasculitis. She was initiated on oral Prednisone 1 mg/kg/day. Three weeks later, she was transitioned to oral Dapsone with a slow prednisone taper. The next day, the patient developed abdominal pain with nausea and vomiting. CAT scan of the abdomen was notable for a large thrombus in the descending thoracic aorta. A thorough workup for small vessel vasculitis was undertaken which was negative with pertinent negative tests including ANCA, Cryoglobulin levels, Rheumatoid Factor, serum electrophoresis, protein C & S, Anti-thrombin 4 level, Anticardiolipin antibody, and Beta-2 glycoprotein level. She was treated with anticoagulation for the aortic thrombus with IV heparin and then later transitioned to oral Rivaroxaban. Repeat CAT scan a month later showed resolution of the clot in the aorta. Regarding the Crohn’s disease, a decision was made to switch her therapy from IFX to Ustekinumab for maintenance of remission.

DISCUSSION:

IgA mediated vasculitis is a rare adverse reaction which can be caused by anti-tumor necrosis factor (TNF) agents and remains poorly understood. It has been described with all the commonly used anti-TNF agents and usually occurs after several months of use. In our patient, this occurred after several years of use. None of the other medications on her list were noted to have an association with IgA mediated vasculitis. Clinical symptoms can range from local cutaneous manifestations to multi-system involvement. In our patient, skin and large vessel (aorta) were involved. The resolution of symptoms may be achieved by discontinuing use of the culprit anti-TNF agent and initiating adjuvant treatment. Alternative non-anti-TNF therapies should be pursued for definitive treatment.
2066 Much Ado About Nothing: Isolated Raised ALP in IBD Patients Due to Macrocomplex
Authors: Gupta Kamesh , Singhania Rohit , Rizwan Shahid , Knox Spencer C.
Published: October 2019

INTRODUCTION:

Macro-Alkaline Phosphatase (ALP) is a rare benign condition characterised by increased plasma ALP activity due to an immunoglobulin-bound form of ALP. Due to an autoimmune process, antibodies can be generated against any of the enzymes, leading to the formation of “macroenzymes”, which interferes with the correct laboratory measurement of the native enzymes. These have been identified for several enzymes including alkaline phosphatase (ALP), amylase, AST, creatine kinase, γ-glutamyl transferase and lactate dehydrogenase.

CASE DESCRIPTION/METHODS:

51-year-old woman with a long-standing history of ulcerative colitis and psoriasis presented for establishing care. She reported alternating diarrhea and constipation and musculoskeletal pains but no jaundice or itching. Her labwork showed normal levels of AST, ALT and total bilirubin but raised ALP (190 units/L, UNL-103). Hepatic origin of raised ALP was confirmed with mildly elevated GGT (42 U/L, UNL- 37). Repeat labs done at monthly intervals showed persistently elevated ALP ranging between 140-240 U/L. She underwent extensive workup to rule out an obstructive pathology, including a USG and MRCP which were unremarkable and liver biopsy which showed preserved hepatic architecture with minimal steatosis. Fractionation of her ALP via gel electrophoresis showed Macro-ALP complexes. She was followed up for a period of 2 years, with persistently elevated ALP but no obstructive symptoms or liver dysfunction.

DISCUSSION:

Isolated raised ALP is a common finding seen in up to 16% of hospitalized patient. However, this becomes concerning in patients with IBD due to its association with disorders of the hepatobiliary system, particularly Primary Sclerosing Cholangitis, seen in upto 5% of IBD patients The mean time from the development of symptoms of IBD to the diagnosis of PSC was 2.3 months. The biochemical parameters are consistent with cholestasis. Our patient was beyond the time frame for the development of PSC and showed no symptoms of signs of cholestasis. Macro-ALP as a cause of persistently elevated ALP has been reported twice earlier in literature. Strategies to identify macro enzymes include polyethylene glycol precipitation,counter-immunoelectrophoresis or gel electrophoresis. In general, the identification of macro-enzyme complexes is important to rule out pathological causes of raised serum enzyme activity and avoid unnecessary and potentially harmful diagnostic investigations.
2067 Beckwith-Wiedemann Syndrome and the Association With Crohn's Disease
Authors: Hudspath Caleb B. , Kozacek Kyler , Manibusan Pedro
Published: October 2019

INTRODUCTION:

Beckwith-Wiedemann syndrome is a congenital growth disorder characterized by macrosomia, organomegaly, abdominal wall defects, and a predisposition for tumor development. The clinical manifestations are caused by epigenetic alterations on chromosome 11p15.5, which encodes tumor protein p57. This protein serves many critical cellular functions to include cell proliferation, differentiation, and apoptosis. Genetic linkage studies have provided strong evidence for the development of inflammatory bowel disease (IBD). Chromosome 11p has been described as a possible IBD loci with susceptible genes. We present the first reported case of a patient with Beckwith-Wiedemann syndrome and Crohn’s disease.

CASE DESCRIPTION/METHODS:

A 30-year-old female with Beckwith-Wiedemann syndrome and a history of Crohn’s disease presented for initial establishment of care. She was diagnosed at age 23 after having symptoms of diarrhea and severe abdominal pain. Her treatment history consisted of mesalamine, mercaptopurine, and most recently infliximab. Infliximab was started after colonoscopy showed active colitis within the ascending, transverse, descending, and terminal ileum. Her complications from Beckwith-Wiedemann syndrome consisted of macroglossia resulting in obstructive sleep apnea. At her six-month follow up the patient had improvement in symptoms and no evidence of active colitis or ileitis.

DISCUSSION:

Genetic associations with IBD have been well studied and indicated a strong basis for the development of IBD. Chromosome 11p has been investigated in a genomic-wide linkage study in Finnish IBD families which reported it as a susceptible loci for IBD. Tumor protein p57, located on chromosome 11p, and its interaction with the well known p53 family has yet to be fully described. This could be an area of further research. Transcription factors within the p53 family have been well studied for their expression within IBD, gastric, esophageal, and colon cancer. The mechanism between chromosome 11p and the development of IBD has not yet been defined. This case involved a patient with a known genetic mutation that has been recently linked to the development of IBD.
2081 Idiopathic Thrombocytopenic Purpura: An Uncommon Extra-intestinal Manifestation of Crohn's Disease
Authors: Epistola Raisa , Do Tiffanie , Hou Linda A. , Fleischman Wayne
Published: October 2019

INTRODUCTION:

Idiopathic thrombocytopenic purpura (ITP) is characterized by the presence of autoantibodies against platelet surface antigens with immune-mediated platelet destruction. While the association of ITP and inflammatory bowel disease (IBD) has been described in few case reports, management of ITP as an extra-intestinal manifestation of Crohn’s disease (CD) is less studied.

CASE DESCRIPTION/METHODS:

A 27-year-old man with history of CD and ITP presented with 3 days of bloody diarrhea and non-bloody, nonbilious vomiting. Physical exam notable for mild periumbilical tenderness, no hepatosplenomegaly present. Admission labs showed platelets of 18, ESR of 49, CRP of 8.04. He was started on IV methylprednisone and given platelet transfusions with only a brief response in platelet count. He was then treated with 2 doses of intravenous immunoglobulin (IVIg). His platelet count had only a transient response to combined steroids and IVIg, so rituximab was given on hospital day 10. He continued to have hematochezia and underwent endoscopy, revealing body and fundus gastropathy as well as moderate-severe proctosigmoiditis. Given a history of thrombocytopenia with adalimumab and infliximab, he received ustekinumab for his CD flare on day 14. He was taken to the operating room for colectomy and splenectomy on day 25 for ongoing CD flare and thrombocytopenia requiring daily transfusions. After surgery, platelets increased without transfusions. Discharge platelet count was 571. Colon pathology showed changes consistent with chronic IBD, severe disease activity. His CD has been controlled on maintenance ustekinumab and 6-mercaptopurine in the 5 months following discharge. Platelets remain stable at 170 without additional medical management.

DISCUSSION:

There are roughly a dozen cases published on the management of dually diagnosed CD/ITP patients. Previous reports postulate that the mechanism of ITP in CD is through the presence of circulating immune complexes in the serum and antigenic mimicry due to increased mucosal permeability in active colitis, which may explain why CD surgery can also result in remission of ITP. Indeed, our literature review identified 1 case where ITP was refractory to steroids and splenectomy, but responded after bowel resection and another case where medically refractory ITP responded to bowel resection alone. These cases, as well as the one we have presented, suggest that colectomy should be considered in the treatment of medically refractory ITP among patients with concomitant CD.
2104 Treatment of Ulcerative Colitis Pan-Enteritis Following Colectomy With Cyclosporine
Authors: Patel Parita , Pekow Joel , Dalal Sushila R.
Published: October 2019

INTRODUCTION:

Extensive enteritis following colectomy for ulcerative colitis is a rare disease phenotype that is often difficult to treat. Surgical intervention can be prevented with initiation of steroids and calcineurin inhibitors.

CASE DESCRIPTION/METHODS:

An 18-year-old female with ulcerative colitis status post colectomy and restorative ileoanal anastomosis presented with bloody diarrhea two months after her ileostomy closure. An EGD and pouchoscopy demonstrated active inflammation in the duodenum and distal 60 cm of small bowel. Pathology revealed acute and chronic enteritis without evidence of cytomegalovirus. Despite prompt initiation of corticosteroids, blood transfusions, and parenteral nutrition, weight loss, diarrhea and anemia persisted. Brief ICU care was required for hypotension and worsening anemia. Intravenous cyclosporine (CyA) was initiated, maintaining a goal range of 300-400 ng/mL. Within 48 hours of cyclosporine salvage therapy, bloody diarrhea, enteral intake and anemia improved. She was discharged on oral prednisone taper and oral CyA, with plans to initiate azathioprine for maintenance of remission.

DISCUSSION:

Ulcerative colitis is defined as inflammation of the colon and rectum only. However, a variant of small bowel inflammation, referred to as ulcerative colitis- related pan enteritis, has been recently identified, with symptoms of nausea, abdominal pain, and bloody diarrhea typically occurring after several months after colectomy. Although the pathogenesis is unknown, some have hypothesized that massive cytokine mediated inflammatory response may continue after colectomy. Endoscopy and pathologic examination are essential for diagnosis with evidence of superficial, continuous ulcerative mucosal inflammation in the stomach and/or small bowel. Lack of aphthous ulcers, skip lesions and strictures can distinguish this entity from Crohn’s disease. The majority of patients will respond to intravenous corticosteroids, but use of calcineurin inhibitors in refractory cases has been reported. Long term management remains undefined, but a recent case series has reported success with use of azathioprine to maintain remission. We report a rare case of ulcerative colitis pan enteritis refractory to corticosteroid therapy, but responsive to intravenous CyA. This should be considered in the differential diagnosis for patients with signs of small bowel inflammation after a colectomy for ulcerative colitis. Prompt recognition and treatment can prevent unnecessary surgical interventions.
2108 CD4 Levels and Viral Load During Ulcerative Colitis Flares in Patients With HIV: A Case Series
Authors: Arroyo-Mercado Fray Martin M. , Likhtshteyn Michelle , Huynh Chi Doan , Chokshi Tanuj , Chawla Gurasees S. , Grossman Evan B. , Ramirez Miguel , Martinez Hector Ojeda
Published: October 2019

INTRODUCTION:

Accumulating evidence indicates an association between CD4 count and Ulcerative colitis (UC) flares in patients with Human Immunodeficiency Virus (HIV)[1,4], whereby patients who have low CD4 counts are less likely to experience UC flares compared to those who have normal CD4 counts. While the exact mechanism is unknown, it is hypothesized that an immunosuppressed state allows for the remission of UC; this idea has been deemed the “Remission Hypothesis” [1].

CASE DESCRIPTION/METHODS:

Objective: To present a case series of 3 patients with concomitant HIV and Ulcerative Colitis (UC) and examine the association between UC flares, CD4 counts and viral load over time.

METHODS:

Patient records at two urban university-affiliated medical centers were queried for patients with concomitant HIV and UC. ICD 9 and ICD 10 diagnostic codes for HIV and UC were used to identify patients. Inclusion criteria were confirmed UC via endoscopy, outpatient follow up, viral load and CD4 count documentation. CD4 counts and viral loads levels were compared during hospitalizations and outpatient follow-ups.

RESULTS:

7 patients with UC and HIV were identified; 3 of these 7 patients had sufficient data available for further analysis. Our three patients lived with HIV for an average of 10 years. Patient 1 experienced 4 UC flares requiring inpatient hospitalizations while maintaining CD4 counts above 250 cells/µL and undetectable viral loads (Table 1). Patient 2 had five UC flares with CD4 counts above 250 cells/µL; an undetectable viral load was noted during 4 of the UC flares (Table 2). Patient 1 had two flares with CD4 counts above 250 cells/µL; the viral load was undetectable during flares (Table 3).

DISCUSSION:

The remission hypothesis suggests that patients who have concomitant HIV and UC can experience remission of their inflammatory bowel disease as their CD4 count declines [1]. HIV viral load is a more accurate and more important marker of HIV disease progression, and therefore, a relationship between viral load and UC flares need to be further studied. Our patients continued to experience flares despite suppressed viral load, and CD4 counts above 250 cells/µL. This case series is the first study that considers viral load and CD4 counts when considering IBD flares and disease progression. These findings raise the question of whether IBD flares occurs as a consequence of CD4 count above 250 or low viral load. Further studies with larger populations are needed to elucidate the pathophysiology of IBD and HIV coexistence.
2117 Anal Squamous Cell Carcinoma Presenting as a Rectal Mass
Authors: Kalinoski Thomas , Singh Simi
Published: October 2019

INTRODUCTION:

Anal squamous cell carcinoma (SCC)typically presents as an anal mass. It rarely presentsin the rectumalone. Limited literature exists to discuss regarding optimal management for this unique presentation. We present a patient withanal SCC manifesting as a rectal mass and reviewher management.

CASE DESCRIPTION/METHODS:

A 73 year-old woman with esophageal reflux presented to our office with chronicrectal bleedingand constipation.She denied anal pain. Colonoscopy revealed a 1.2 cm massin the anterior rectum, 2 cm from the anal verge (Figure 1). Biopsies revealed focally invasive nonkeratinizing SCC (Figure 2). On rectal endoscopic ultrasound (EUS), the mass was confined to the anus andextended from the anorectal canal into the rectum (Figure 3). Submucosal invasion was noted, but not through the rectal muscularis propria. PET CT showed no perirectal invasion, lymphadenopathy, metastatic disease orother sources of primary SCC. Final staging was T2N0. She underwentchemoradiationwith5-fluorouricil and mitomycin. Surgery was deferred to preserve anal function.Her tumor showed a complete response after 6 weeks and she is currently being followed with routine surveillance.

DISCUSSION:

Anal SCC makes up2.6% of digestive system cancers in the United States, but its incidence is rising in men and women, possibly due to changes in sexual behavior and increasing rates of HPV exposure. Gastroenterologists should recognizeatypical presentations ofanal SCC, especially in high-risk populations: men who have sex with men, HIV positive patients, and women with high risk HPV. Rectal bleeding and altered bowel habits arethe most commonlyreported symptoms. Other symptoms include anal mass, pain, itching, and mucous discharge, but up to 20% of patients with anal cancer are asymptomatic. The absence of anal pain and external lesions as well as the rectal mass on in our patient suggested an alternative diagnosis. Given that management of rectal cancer has traditionally centered around resection, this emphasizes the utility of EUS to make the correct diagnosis and direct management. The management of this unique presentation of anal SCC has not been fully established, but our patient received standard chemoradiation with good results. Anal SCC has a range of presentations and can present as a rectal mass. Given that anal SCC rates are increasing, our case highlights the importance of disease screening, recognition, and prevention.
2118 A Challenging Case of Recurrent Rectal Adenoma Despite Multiple Endoscopic Mucosal Resections (EMRs) and Trans-Anal Endoscopic Microsurgeries (TEMS)
Authors: Syed Tausif A. , Enslin Sarah , Tirumanisetty Pratyusha , Fleming Fergal , Kaul Vivek
Published: October 2019

INTRODUCTION:

Detection and complete removal of colorectal adenomas is essential in reducing the incidence and mortality of cancer. Advanced rectal adenomas can be removed by a number of techniques including Endoscopic Mucosal Resection (EMR), Endoscopic Submucosal Dissection (ESD) and Trans-anal Endoscopic Microsurgery (TEMS). Despite complete resection, local recurrence remains a challenge in some patients. We report a rare case of a recurrent rectal adenoma despite multiple EMRs and TEMS procedures over a 5-year period.

CASE DESCRIPTION/METHODS:

A 63-year female was referred for EMR of a 2 cm rectal adenoma found on screening colonoscopy 5 years ago (Figure 1). Colonoscopy with en-bloc EMR was done without difficulty. On 6-month follow-up a recurrent adenoma was seen at EMR site. En-bloc EMR was again performed followed by argon plasma coagulation (APC) ablation of edges. Follow-up flexible sigmoidoscopy 6-months later again showed a recurrent adenoma. Patient was referred for TEMS; full-thickness resection was performed with negative margins on pathology specimen. Surveillance colonoscopy 6 months after TEMS revealed recurrent adenoma at the TEMS site. TEMS was repeated. Follow-up endoscopic examination and biopsy 2 months and 1 year after the second TEMS revealed no evidence of lesion recurrence (Figure 2). However her most recent colonoscopy, 3 years after the second TEMS, showed a recurrent 6 mm sessile adenoma at same site (Figure 3). After multidisciplinary consultation, she is scheduled to undergo a third TEMS procedure.

DISCUSSION:

The reported incidence of recurrent rectal adenoma is 4-11%. Factors affecting local recurrence include size of index polyp and completeness of resection. Despite complete resection, some patients will develop repeated recurrence. Ramkumar et al. reported 669 patients who underwent TEMS for treatment of rectal lesions; 15 pts required 3 or more TEMS procedures. Repeat TEMS was shown to be safe with similar postoperative complications and similar rates of margin clearance (81% vs 88%, P = 0.09) compared to primary TEMS
1
. In our patient, a rectal adenoma recurred despite 2 en-bloc EMRs and 2 TEMS. This demonstrates the need for close surveillance and the importance of a multi-disciplinary treatment approach in these patients.
2138 Percutaneous Endoscopic Jejunostomy Tube Placement for Treatment of Severe Hyperemesis Gravidarum in Pregnancy: Case Report and Review
Authors: Kruchko David H. , Shah Natasha , Broy Charles , Silas Dean N.
Published: October 2019

INTRODUCTION:

Hyperemesis gravidarum (HG) is a severe complication of pregnancy that occurs in up to 2% of pregnancies nationwide. Symptoms range from nausea and vomiting, leading to dehydration, electrolyte imbalances, and ultimately, fetal and maternal compromise. Medical management is not always adequate for symptomatic control with HG patients and enteral feeding is required via a nasoenteric or percutaneous endoscopic gastrostomy (PEG) tube. We present a rare case of a pregnant female with HG that failed the mentioned above therapy and required a percutaneous endoscopic transgastric-jejunostomy (PEG-J) tube for post pyloric feeding.

CASE DESCRIPTION/METHODS:

A 27-year-old-female with a past medical history of HG in all prior pregnancies required nasojejunal (NJ) tube placement at approximately 20 weeks gestation due to weight loss from 30 episodes of emesis daily. She developed a posterior oropharyngeal ulcer requiring NJ tube removal. The decision to bypass intra-gastric feeding with a PEG-J tube was determined to be the best option for nutrition. A 24Fr PEG was placed, and a 12Fr jejunostomy catheter was passed through the PEG into the jejunum (A). Unfortunately, she returned as an outpatient 12 later with worsening symptoms. Abdominal radiograph revealed the jejunal portion of the tube to be in the distal stomach (B). The patient underwent a repeat upper endoscopy and PEG-J tube dislodgement was confirmed. The PEG-J was removed and an externally removable 22Fr low-profile PEG-J tube was placed using the existing gastrostomy stoma. Proper position of the tube was confirmed and the distal tip was secured to the jejunal wall with three hemoclips (C). The patient and fetus tolerated the procedure without complication and she went on to receive tube feeds through the PEG-J tube for the remaining 18 weeks of pregnancy. The PEG-J tube was removed with manual traction post-partum day 1 at the bedside after the patient was asymptomatic and tolerating general diet.

DISCUSSION:

There is very little recent literature on refractory HG cases requiring PEGJ-tube placement. This case demonstrates the importance of following a stepwise approach for nutritional support in refractory HG patients and that low-profile PEG-J can be a well-tolerated and safe treatment modality option in those who have failed conservative therapy. As seen in this case, PEG-J tube dislodgement is a potential complication but can be prevented effectively with hemoclips and therefore should not be a limiting factor for placement of PEG-J tube.
2142 Endoscopic Management Cases for Small Bowel Obstruction
Authors: Urakawa Shinya , Kono Yohei , Momose Kota , Alzghari Talal , Milsom Jeffrey
Published: October 2019

INTRODUCTION:

Small bowel obstruction (SBO) is a common disease in the gastrointestinal surgery field. Although causes of SBO are highly variable, surgical management is usually selected for adhesive obstruction if nasogastric tube decompression has failed. There have been no reports of endoscopic cure for SBO, despite several reports of endoscopic management of colonic voluvulus or malignant colonic obstruction. Here we report three cases in which endoscopic reduction was safely performed for SBO.

CASE DESCRIPTION/METHODS:

Case1: An 86-year-old woman developed obstruction one month after right hemicolectomy for colorectal cancer. Preprocedural CT scan imaging detected a lumen caliber change near the ileocolonic anastomosis, and no recovery sign was acquired even after decompression treatment by nasogastric tube for 3 days. Colonoscopy with fluoroscopy showed ileum kinking at 10 cm proximal from the anastomosis. Case2: A 68-year-old woman developed obstruction during hospitalization for myelodysplastic syndrome. She had past surgcal history of 7 caesarean sections. Preprocedural CT scan imaging showed terminal ileum with transition point at 20 cm from ileocecal valve. Colonoscopy was performed after one week of conservative management. Colonoscopy with fluoroscopy revealed strong angulation and stricture accompanied by ulcerations at the terminal ileum. Case3: A 79-year-old woman developed obstruction one year after cystectomy with Indiana pouch reconstruction for bladder cancer. There was no improvement sign after 5 days of nasogastric tube and supportive treatment. Colonoscopy with fluoroscopy revealed ileum kinking 20 cm proximal to the ileocolic anastomosis, consistent with preprocedural imaging. In all 3 cases, the scope passed through the obstruction site following insertion of a guide wire and stiff catheter through above the obstruction area. All obstructions were successfully released. The passage of the contrast intraoperatively through the site was clearly observed. In Case 3 was added balloon dilation after the endoscope withdrawal. All patients were discharged without additional surgery or postprocedural complications, with 1.5-4 months follow up.

DISCUSSION:

We report three cases in which endoscopic treatment safely treated for SBO likely due to adhesions. Endoscopic management could release the obstruction earlier than predictable course in these three cases. These cases show the potential for endoscopic treatment to replace surgical treatment in a certain type of SBO.
2149 Successful Stenting of the Common Bile Duct Through an Ectopic Ampulla of Vater in the Pylorus
Authors: Markel Nathan L. , Nguyen Vu N.
Published: October 2019

INTRODUCTION:

The ampulla of Vater comprises the choledochopancreatic junction and sphincter of Oddi, traversing the posteromedial wall of the descending duodenum via the major papilla. Ectopic gastric ampullae are rare, and since the 16th century, pyloric ampullae of Vater are only documented in a handful of case reports
1
. We present a case of an extremely rare ectopic ampulla of Vater in the pylorus through which successful stenting of the common bile duct (CBD) was performed during ERCP.

CASE DESCRIPTION/METHODS:

A 51-year-old man presented with nausea, vomiting, and midepigastric pain radiating to the back. He was tachycardic to 117 bpm with right upper quadrant tenderness on exam. Labs showed WBC 13.5 × 109/L, AST 123 IU/L, ALT 186 IU/L, ALP 722 IU/L, lipase of 195 IU/L, and total bilirubin of 3.1 mg/dL. Contrast CT revealed a distended gallbladder with wall thickening and pericholecystic fluid, intrahepatic and extrahepatic biliary dilatation, and calcified CBD stones with pancreatic duct dilatation. Ultrasound confirmed a sonographic Murphy sign and a 9 mm CBD. After receiving intravenous ciprofloxacin and metronidazole, he underwent ERCP. Initial attempts to locate the ampulla in the duodenum were unsuccessful with a side-viewing scope. Eventual use of a forward-viewing scope identified the ampulla and a clean based ulcer in the pylorus. Purulent drainage was observed following sphincterotomy and balloon extraction. A 7 French x 5 cm stent was carefully deployed in the CBD. Prior to discharge, the patient underwent uncomplicated laparoscopic cholecystectomy. Stent was successfully retrieved 6 weeks later, again using the forward-viewing scope. Biopsies of the ampulla and ulcer confirmed acute and chronic gastritis negative for H. pylori or malignancy.

DISCUSSION:

As in the present case, literature suggests a recurrent triad of choledocholithiasis, cholangitis, and ulcer disease, perhaps due to reflux of gastric secretions into the hepatobiliary tree and increased mucosal exposure to pancreaticobiliary secretions. To the authors’ knowledge, this case possibly represents the first successful stenting of the CBD through an ectopic ampulla of Vater in the pylorus, proving that this can be a safe and effective option. Gastroenterologists should be aware of ectopic anatomy when the ampulla cannot be located in the duodenum.
2152 A Novel Technique Using Hemostatic Spray and Endoscopic Stent-in-stent for Palliation of Hemorrhaging Esophageal Cancer
Authors: Khalid Ammara , Al-Salameh Nizar , Pluskota Christopher , Khara Harshit S.
Published: October 2019

INTRODUCTION:

Most esophageal cancers present at an advanced unresectable stage; thus, the main focus is on palliative treatment and symptom management to improve quality of life. Esophageal stents in combination with radiation therapy are commonly used to palliate dysphagia and bleeding in these patients. We describe a novel case of an advanced metastatic esophageal cancer presenting with a massive GI bleed, treated successfully with hemostatic spray and stent in stent technique.

CASE DESCRIPTION/METHODS:

A 61-year-old male with recent diagnosis of stage IV esophageal adenocarcinoma was transferred to our hospital with a massive GI bleed. He had undergone an emergent EGD at that facility with unsuccessful endoscopic hemostasis of the profusely bleeding esophagus mass. We performed a repeat EGD, that showed a 20 cm long, diffusely bleeding partially obstructing malignant esophageal tumor. We achieved successful endoscopic hemostasis with the use of the hemostatic spray, followed by EUS-guided fiducial marker placement at the proximal and distal ends of the tumor in preparation for stereotactic radiation therapy. The entire length of the tumor was then stented using the 20 mm × 15 cm and a 20 mm × 8 cm through-the-scope fully covered esophageal metal stents with a stent-in-stent technique for tamponade of bleeding and palliation of dysphagia. He did not have any further rebleed episodes and was able to successfully receive palliative radiation as outpatient with improved quality of life at 6 months follow up.

DISCUSSION:

Treatment of advanced esophageal cancers is mainly based on palliative management. Chemo or radiation therapy can provide palliation in patients with unresectable disease. Our case highlights the use of a novel approach with combined use of hemostatic spray and stent-in-stent technique as a bridge to radiation therapy after adequate control of tumor bleeding, facilitating palliative radiation therapy and improved quality of life and survival.
2155 A Minimally Invasive Approach to Resection of a Duodenal Neuroendocrine Tumor Using the Full-Thickness Resection Device
Authors: Walsh Leonard , Groff Andrew , Moyer Matthew
Published: October 2019

INTRODUCTION:

The Full-Thickness Resection Device (FTRD) allows for diagnostic and therapeutic endoscopic full-thickness resection (EFTR) of lesions that are unresectable with conventional endoscopic techniques. The device offers a minimally invasive approach to full thickness resection of intestinal and rectal lesions, and ensures safe tissue closure with over-the-scope-clip (OTSC) technology. We report a patient in whom the FTRD system was used for R0 resection of a duodenal neuroendocrine tumor.

CASE DESCRIPTION/METHODS:

A 68 year-old-male with history of Barrett’s esophagus was found to have a low-grade neuroendocrine tumor of the duodenal bulb on surveillance upper endoscopic screening. Computed tomography (CT) imaging of the abdomen revealed a hypervascular duodenal bulb mass, without obvious extension to the wall, lymphadenopathy, or evidence of metastasis. Endoscopic ultrasound (EUS) with fine needle aspiration (FNA), revealed a 1.2 cm mass arising from the submucosal layer with pathology indicating a low-grade neuroendocrine tumor. Due to the small tumor size, EFTR by FTRD was planned. Upon advancing the endoscope with the FTRD system attached, a non-bleeding neuroendocrine tumor was visualized (Figure 1). The mass was carefully pulled into the cap and after banding, ligation and cutting; there was a full thickness en bloc resection with all layers of the duodenum apparent (Figure 2). Pathology of the specimen documented a grade 2 neuroendocrine tumor with clean margins, confirming R0 resection (Figure 3). The patient was discharged the same day without associated complications.

DISCUSSION:

Upper gastrointestinal endoscopy and histologic examination are essential for diagnosis of duodenal neuroendocrine tumors, and EUS should follow for determination of size and depth of infiltration as well as determination of locoregional lymph node involvement. Multiple factors, such as tumor size, location, and grade need to be considered when determining treatment options. The FTRD system offers a novel endoscopic treatment approach to tumors extending beyond the submucosa that require full thickness resection and would otherwise require higher risk surgical intervention. The technology allows for safe tissue closure, valid histologic evaluation of the en-bloc specimen, and minimal thermal injury, thus reducing the morbidity and cost otherwise associated with surgery. Our case illustrates the successful R0 resection of a T2, grade 2 neuroendocrine tumor using the FTRD.
2157 A Novel Case of Plasma Cell Leukemia Diagnosed by Endoscopic Ultrasound With Fine-Needle Biopsy
Authors: Joseph-Talreja Mairin , Cummings Donelle , Chum Christopher , Cheung Derrick
Published: October 2019

INTRODUCTION:

There are numerous reports of endoscopic ultrasound (EUS) with fine needle aspiration (FNA) used to diagnose plasmacytoma of the GI tract but, to our knowledge, this is the first report of plasma cell leukemia diagnosed by EUS with fine needle biopsy (FNB).

CASE DESCRIPTION/METHODS:

A 78 year old woman presented with exertional chest pain, dyspnea, and unquantified unintentional weight loss. CT chest showed bilateral pleural effusions, left pleural soft tissue masses, and multiple paravertebral soft tissue masses. Thoracentesis was non-diagnostic. She re-presented a month later with the same symptoms. Repeat imaging revealed enlargement of the lesions and the decision was made to pursue EUS-FNB to obtain tissue for diagnosis. On endoscopy, the patient was found to have gastric erosions and two non-bleeding, ulcerated nodules in the fundus. Biopsies resulted in chronic gastritis and h.pylori. EUS described one enlarged lymph node visualized in the middle para-esophageal mediastinum, surrounded by hyperechoic hazy soft tissue. The lymph node measured 30.6 mm by 18.5 mm, with irregular, poorly defined margins. A second lymph node was found in the peri-pancreatic region, measuring 19.4 mm × 15 mm. FNB was performed. The pathology report from both nodes identified sheets of atypical plasma cell proliferation which stained positive for CD138 and CD56. Flow cytometry revealed a proportion of 40% IgG Lambda-restricted plasma cell population. These findings, taken in the context of a known M-spike and circulating atypical IgG lambda-restricted plasma cells on peripheral blood smear, established the diagnosis of plasma cell leukemia with soft tissue component. Unfortunately, it was felt that the patient would not be able to tolerate chemotherapy and she was sent home with hospice.

DISCUSSION:

While EUS-FNA is used frequently to evaluate lesions in the upper GI tract, this is the first reported case, to our knowledge, of EUS-FNB used to diagnose a plasma cell leukemia. In this case, the diagnosis was confirmed, not on peripheral smear or with cytology from pleural fluid, but from the biopsies we obtained. This is a good example of how EUS-FNB can often be the safest and easiest way to obtain adequate tissue samples from intrathoracic or intraabdominal lesions to facilitate diagnosis.
2169 Endoscopic Stricturotomy via Argon Plasma Coagulation With Balloon Dilation for Refractory Colonic Stricture Secondary to Crohn’s Disease
Authors: Ali Saad Emhmed , Tripathi Nishant , Bautista Robert-Marlo , Gabr Moamen , Mardini Houssam , Frandah Wesam
Published: October 2019

INTRODUCTION:

Stricture is a significant complication in patients with Crohn’s disease (CD). Up to 80 % of patients will require at least one surgery for stricture, fistula, or abscess during their lifetime. The current treatment modalities are surgery, endoscopic balloon dilation (EBD), or endoscopic stricturotomy (ES) via a needle-knife or electrosurgical knife. We report a combined endoscopic stricturotomy via argon plasma coagulation (APC) with balloon dilation in a patient with refractory benign colonic stricture due to Crohn disease.

CASE DESCRIPTION/METHODS:

A 56-year old man with a twenty-seven-year history of Crohn’s disease presented to the clinic with chronic right-sided abdominal pain. He has two to three bowel movements a day. He is a non-smoker, denied alcohol, or illicit drug use. He had prior use of anti-TNF inhibitor with secondary loss of response. Current medication included azathioprine, esomeprazole, and ustekinumab injection every eight weeks. Vital signs were normal. The abdomen was soft, non-tender, no organomegaly, normal bowel sounds, and normal rectal exam. Labs revealed hemoglobin 14.2 g/dl, leukocyte count 7k/mm3, platelets 393k/mm3, urea nitrogen 13 mg/dl, creatinine 1.0 mg/dl, CRP 0.9, mg/dl and fecal calprotectin 59 ug/g. Magnetic resonance enterography (MRE) was performed and revealed severe short segment stricture of the mid ascending colon (Figure 1). He underwent a colonoscopy, and it showed a benign-appearing, severe non-traversed stricture measuring 3 cm in length x 1.1 cm in inner diameter in the ascending colon (Figure 2). Coagulation for tissue destruction and stricturotomy using pulsed argon plasma at 1.5 liters/minute and 40 watts was accomplished, followed by balloon dilator up to 15 mm with significant improvement in the luminal narrowing (Figure 3). The site was traversed, and the cecum was inspected. The patient was seen in the clinic two months later, and he was doing well, and his abdominal pain was resolved.

DISCUSSION:

Surgery is still considered to be the standard therapy in patients with a colonic stricture. Endoscopic stricturotomy has emerged as a promising modality to avoid or minimize the need for surgery. Up to our knowledge, using the APC mediated ES has not been reported. So, we report the successful use of this technique combined with balloon dilation in a patient with severe CD- associated benign stricture. The clinician should be aware of such procedure as an effective treatment modality in refractory benign colonic stricture.
2179 Placement of Palliative Stent With Guidance of a Percutaneous Transhepatic Stent
Authors: Poola Shiva , Jampala Nannaya , Mudireddy Prashant
Published: October 2019

INTRODUCTION:

The incidence of pancreatic cancer has increased in the last decade. There have been improvements in pancreatic cancer through a multidisciplinary approach including chemotherapy, surgery, and radiation. The Whipple procedure is the mainstay operation for pancreatic head tumors; however, long term complications include cholangitis and pancreatitis. Cholangitis can be managed with drainage or stenting. Although PTC stent allows for drainage of the biliary system, an obstruction may call for internal stent placement. This case highlights placement of a stent using a pre-existing PTC drain for guidance.

CASE DESCRIPTION/METHODS:

A 71-year-old Caucasian male with history of pancreatic cancer status post a Whipple and chemoradiation presented with obstructive jaundice. EGD demonstrated a malignant stricture of the afferent jejunal limb. Attempted endoscopic stenting was unsuccessful. An 8.5 Fr PTC with internal and external biliary drainage catheter was performed by IR with the internal drainage catheter placed beyond the stricture. The patient over the course of the next month had decreased output from his biliary drain and was re-admitted with increased bilirubin and leukocytosis. The external/internal biliary drain catheter was replaced without significant improvement. A repeat EGD and ERCP demonstrated a PTC drain in the afferent jejunum and using a biliary wire through the side hole of the PTC drain, the PTC drain was removed over the wire. An uncovered metal stent was placed across the afferent jejunal stricture into the normal jejunal limb. Post procedurally the patient had improved LFTs. However, the patient had an interval rise in bilirubin and ALP. EGD demonstrated a clogged stent and a pigtail plastic stent was placed through the preexisting metal stent to prevent recurrent clogging. After the patient had improvement in his LFTs.

DISCUSSION:

Management of biliary obstructions requires biliary drainage with either a stent or surgical drainage. This case highlights a multi-step approach for management of a malignant biliary obstruction. After identifying an obstruction, an internal metal stent was placed in a rendezvous approach. Endoscopic metallic stent placement is a common for malignant biliary obstructions in jaundiced pancreatic cancer patients. In an event of an occluded metal stent, placement of a plastic stent is effective for management. This patient had a biliary obstruction after metallic stent placement prompting placement of a plastic pigtail stent within the metal stent.
2183 Endoscopic Management of Efferent Loop Syndrome Using Axios Lumen-Apposing Metal Stent
Authors: Zivari Kaveh , Waintraub Daniel J. , Fazio Richard M. , Weinberger Jonathan , Chernobelsky Leonid , Moshenyat Isaac , Khodorskiy Dmitriy O.
Published: October 2019

INTRODUCTION:

Efferent loop syndrome (ELS) is a rare post gastrectomy syndrome that can occur following Billroth-II or Roux-en-Y reconstruction. The most common loop syndrome after gastric surgery is afferent loop syndrome (ALS), however efferent loop syndrome has been reported. ELS may occur due to a mechanical obstruction of the efferent limb due to an anastomotic stricture, malignancy, volvulus, intussusception, internal hernia or abdominal adhesion after surgery. Presentations include abdominal distension and vomiting and rarely pancreatitis or cholangitis. We present a case of efferent loop syndrome managed with an Axios lumen apposing metal stent (LAMS).

CASE DESCRIPTION/METHODS:

79 year-old male with a history of gastric adenocarcinoma status post distal gastrectomy with Billroth-II reconstruction one month prior to admission presented with abdominal pain and nausea. Computed tomography of the abdomen revealed distended stomach with contrast, dilated biliary limb with collapsed distal jejunum and no passage of contrast distal to the anastomosis (Image 1). Upper endoscopy (EGD) revealed a friable gastrojejunostomy anastomosis with a patent afferent limb and a nearly obstructed stenosis at the efferent limb suture line. A 20 × 10 mm A-LAMS was deployed across the stenosed efferent limb under direct visualization and fluoroscopic guidance (Images 2 and 3). Follow up upper gastrointestinal series confirmed brisk passage of contrast into the efferent limb. The patient clinically improved and a repeat EGD revealed a patent efferent limb and a dislodged Axios LAMS which was endoscopically removed.

DISCUSSION:

ELS and ALS can be managed surgically or endoscopically. Endoscopic options include dilation and enteral stenting. Dilation may require multiple sessions and stenting utilizing self-expanding metallic stents (SEMS) may be limited by tumor in-growth in the setting of malignant obstruction. LAMS creates a de-novo fistulous tract to bypass an obstruction while its saddle shape provides anti-migratory properties and allows apposition of two gastrointestinal lumens. While LAMS has been reported in ALS, there are only rare reports in the management of ELS. Our case highlights a case of successful management of ELS with Axio LAMS.