bluuebunny/crossref_metadata_2025 huggingface dataset:
1815 Acute Esophageal Necrosis Masquerading as Acute Coronary Syndrome in an Uncontrolled Diabetic
Authors: Yuridullah Ruhin , Patel Varun , Melki Gabriel , Bollu Janardhan
Published: October 2019

INTRODUCTION:

Acute esophageal necrosis (AEN) also known as “black esophagus,” “acute necrotizing esophagus,” or “Gurvits syndrome” is a rare syndrome with characteristic endoscopic finding of circumferential black appearance of the esophagus beginning at the gastroesophageal junction (GEJ) and extending proximally at variable lengths. Etiology is multifactorial with certain predisposing factors including diabetes mellitus. Most patients present with an acute upper gastrointestinal bleed, though other symptoms such as dysphagia, epigastric pain, and chest pain have been described. Herein, we present a case of isolated AEN in a patient with uncontrolled diabetes whose symptoms were mistaken for acute coronary syndrome.

CASE DESCRIPTION/METHODS:

An 80-year-old male with past medical history of hypertension, dyslipidemia, and uncontrolled diabetes mellitus was seen in the emergency department with a 1-hour complaint of epigastric and severe central chest pain accompanied by nausea and two episodes of coffee-ground emesis. A CT of abdomen/pelvis without contrast as well as cardiovascular work-up was unremarkable except for mildly elevated troponins of 0.062 ng/mL. Narcotics and nitroglycerine failed to resolve the chest pain prompting initiation of acute coronary syndrome (ACS) in consideration for non-ST-segment myocardial infarction (NSTEMI). Patient underwent an unremarkable cardiac catheterization. Due to persistent abdominal and chest pain, Gastroenterology were consulted. Subsequent esophagogastroduodenoscopy (EGD) showed circumferential, black-appearing, necrotic esophageal mucosa extending from the mid to distal esophagus consistent with AEN. Patient had an uneventful 5-day hospital course and discharged with close follow up.

DISCUSSION:

Acute esophageal necrosis (AEN) is a rare condition described by pathognomonic endoscopic findings of circumferential black appearance of the esophagus extending distally to the gastroesophageal junction (GEJ). It typically presents with an acute upper gastrointestinal bleeding, epigastric pain, and chest pain. In the case of our patient, severe and relentless chest pain along with episodes of hematemesis in the absence of significant EKG and laboratory findings, and failure of adequate narcotic analgesics to relieve symptoms should have prompted seeking alternative diagnoses. This case illustrates an example of AEN masquerading as ACS leading to delay in management.
1818 Acute Hematemesis From Kayexalate-Induced Esophageal Ulcer
Authors: Kumar Kishore , Essrani Rajesh Kumar , Tariq Hassan , Chime Chukwunonso U. , Dev Anil
Published: October 2019

INTRODUCTION:

Hyperkalemia is one of the most common electrolyte abnormalities encountered in clinical practice. The treatment of hyperkalemia includes removal of the unwanted potassium from the body by cation exchange resins. e. g sodium polystyrene sulfonate (Kayexalate). The serious gastrointestinal side effects of sodium polystyrene sulfonate (SPS) have been reported with or without concomitant use of sorbitol including colonic perforation. The U.S food and drug administration (FDA) has issued a warning to avoid kayexalate administration with sorbitol. We present an individual with acute hematemesis due to bleeding esophageal ulcer immediately after treatment with kayexalate therapy.

CASE DESCRIPTION/METHODS:

63-year-old Hispanic man who was recalled to ED by renal team due to elevated potassium level of 6.6mg/dl. On arrival to ED his vitals were WNL. His physical examination includes distended non- tender abdomen and 2+ pitting edema of lower extremities. Rest of physical was within normal limits. His comorbid conditions include alcohol related decompensated cirrhosis, nephrotic syndrome and small nonbleeding esophageal varices seen on endoscopy performed 3 weeks before current illness. He was treated with oral kayexalate 30mg along with intravenous (I/V) dextrose, calcium gluconate and insulin. 45 minutes after oral SPS therapy patient developed large episode of hematemesis. He was intubated for airway protection. An emergent endoscopy was performed which showed multiple round, sharply demarcated, esophageal ulcers with mucosal oozing (Figure 1A) and small non bleeding esophageal varices were again seen. The two of the esophageal ulcers were actively oozing, to achieve the hemostasis, two hemostatic clips were deployed with cessation of bleeding (Figure 1B). The esophageal ulcer biopsies were not taken due to concern of causing iatrogenic bleeding in the presence of coagulopathy. He had no evidence recurrent gastrointestinal bleeding.

DISCUSSION:

Kayexalate induced colonic ulcer, colonic ischemia and colonic necrosis has been repeatedly described in the literature. The kayexalate induced esophageal ulcer with significant hematemesis is rarely reported. Although the exact mechanism by which kayexalate causes esophageal ulcer to be elucidated but it is worthwhile to be vigilant about its potential adverse effects. Our case highlights the rare but certainly the life threatening complication of kayexalate therapy.
1819 The Black Esophagus in the Renal Transplant Patient
Authors: Yu Michael , Mulki Ramzi , Massaad Julia
Published: October 2019

INTRODUCTION:

Acute esophageal necrosis (AEN) is an uncommon disease characterized by gastrointestinal bleeding and endoscopic findings of circumferential black-colored necrosis of the distal esophagus. Patients at risk include elderly males over the age of 65, who typically have multiple chronic medical issues including vascular disease and diabetes. Mortality is reported to be 32%. Here, we present a case of AEN in a renal transplant patient and describe potential inciting factors such as immunosuppression and opportunistic diseases.

CASE DESCRIPTION/METHODS:

A 35-year-old male with ESRD from hypertensive nephrosclerosis s/p kidney transplant presented with worsening chronic right foot pain. He was found to have right lower extremity limb ischemia was started on heparin. On hospital day 3, he underwent successful revascularization of his R lower extremity. Post-procedural WBC and Hb were 20,000/mL and 12.5 g/dL, respectively. On postoperative day (POD) 3, WBC worsened to 25,400/mL and Hb decreased to 9.6 g/dL. On POD4, he had 3 episodes of melena and his HB dropped to 7.3 g/dL. EGD showed LA Grade D esophagitis in the mid and distal esophagus with necrotic appearing mucosa in the distal esophagus. A CT chest/abdomen with oral contrast performed after the EGD showed circumferential thickening of the distal esophagus. Patient was treated with sucralfate and pantoprazole. He was bridged to warfarin and discharged. On follow up, his Hb improved to 10.9 g/dL.

DISCUSSION:

Our patient was admitted for limb ischemia likely aggravated by peripheral vascular disease of renal disease. He underwent revascularization of his right lower limb which added a component of hemodynamic compromise. As a renal transplant patient, he has multiple comorbidities placing at risk for developing AEN. First, kidney disease gives a higher chance of developing vascular disease. Next, as a transplant patient, he was receiving various immunosuppressing agents like corticosteroids and MMF which also reduce the protective function of the gastrointestinal mucosa. Other risk factors include opportunistic infections and transplant rejection. Caution is needed when caring for renal transplant patients, and following major procedures with significant hemodynamic insult, an EGD should be considered.
1821 Post-Fundoplication Esophageal Bezoar Resolved With Endoscopic Instillation and Oral Ingestion of Cola
Authors: Padhya Kunjali , Dhamija Ankit , Carlson Christopher , Farivar Alexander
Published: October 2019

INTRODUCTION:

We present a difficult bezoar-like esophageal food impaction which occurred 6 months after repair of a giant Type IV hiatal hernia.

CASE DESCRIPTION/METHODS:

The patient is an active 90-year-old female who had a giant Type IV paraoesophageal hernia containing stomach and colon for many years. She underwent repair with mesh and a loose Nissen fundoplication (58 Fr). Pre-operative esophageal manometry was not performed. Post-operative esophagram showed intact wrap, with “3 mm minimum diameter central luminal channel through the fundoplication.” Preserved esophageal motility was also noted. Recovery was uneventful. Six months later, she presented to the ED complaining of sensation of food stuck in her throat. She was tolerating secretions and tiny sips of water. Barium esophagram revealed “dilated distal esophagus, with contrast pooling above retained material at the GE junction”. EGD was performed under general anesthesia. The distal esophagus was completely obstructed with food. Despite use of multiple tools including net, rat-tooth forceps and pronged graspers, it could not be cleared. Using small instillations of cola through a 60 cc syringe, we were able to “tunnel” through the impaction and create a lumen into the stomach. Retroflexion showed a small hiatal hernia. After more than 2 hours, there was still a significant amount of food adherent to the walls of the esophagus. The patient was extubated and admitted to the hospital. She was instructed to drink small sips of cola and ice chips upright in bed. She ingested 2 L of cola over the next 8 hours without difficulty. EGD the next day noted complete passage of food. There was no frank ring or stricture. Fundoplication was intact with a small(2 cm) hiatal hernia. She was discharged the same day on soft diet. At follow up with thoracic surgery she had no further dysphagia episodes. She was instructed to drink cola once a day for maintenance.

DISCUSSION:

Although the patient had a loose wrap and no known dysmotility, post-op diameter of the esophageal lumen was fairly small (3 mm). If patient was not adhering to post-fundoplication diet, this likely precipitated “packing” of food into the distal esophagus and remnant small hernia. Removal of esophageal food impaction is most commonly done by pushing food into the stomach, or removing it mechanically. The use of proteolytic enzymes e.g. papain is not recommended due to perforation risk. One can consider adding cola to the arsenal of tools for safely treating difficult esophageal food impactions.
1832 Adenocarcinoma Arising From a Cervical Esophageal Inlet Patch: The Malignant Potential of a Small Lesion
Authors: Dziadkowiec Karolina N. , Szu Eric , Delaflor-Weiss Eduardo , Proenza Jose
Published: October 2019

INTRODUCTION:

Inlet patches (IP) are heterotopic lesions consisting of gastric mucosa. Commonly located in the cervical esophagus, it is believed that they are remnants of fetal columnar epithelium. A rare complication of IP is the development of esophageal adenocarcinoma. We report a case of a 59-year-old male with intractable cough and dysphagia that was found to have a malignant transformation of an IP.

CASE DESCRIPTION/METHODS:

A 59-year-old white male, with heart failure, obesity, and smoking history, presented with 5 months of cough, bilateral neck pain, globus sensation, and progressive dysphagia. Barium swallow noted an irregularity at the distal cervical esophagus and esophagogastroduodenoscopy (EGD) revealed a stricture extending 17 to 20 cm from the incisors. Pathological analysis from random biopsies returned negative for dysplasia or malignancy. Routine laboratory analysis was unremarkable. The patient returned two years later, complaining of progressive dysphagia. Repeat EGD was performed and immunohistochemical staining on repeat biopsy revealed adenocarcinoma that was: CK7+, CK20-, and variable for CDX2. Pathology revealed adenocarcinoma of the cervical esophagus, invading at least the lamina propria, arising from ectopic gastric mucosa (a cervical IP). The patient was deemed a poor surgical candidate and was treated with palliative carboplatin and paclitaxel with adjuvant radiation therapy.

DISCUSSION:

Most IPs are asymptomatic and are discovered incidentally during EGD, but rarely they may present with reflux, esophagitis, stricture or ulcer formation and produce symptoms of throat pain, dysphagia and globus esophagus. Their prevalence varies from less than 1% to 14%. The incidence of adenocarcinoma arising from a cervical IP is reported to be 1.5% or less. Our patient developed proximal esophageal adenocarcinoma from a cervical IP. EGD images showed no continuity of non-malignant mucosa with the stomach. In addition, the absence of goblet cells indicates a high likelihood that this malignancy originated from the cervical IP. Currently, there are no guidelines to guide the management of incidentally discovered IPs. Some studies recommend routine endoscopic surveillance, although prospective data have failed to demonstrate long-term benefits. With mounting evidence, it is clear that IPs carry significant clinical importance due to their malignant potential. This case demonstrates the need for increased awareness in identifying and managing these lesions discovered during routine endoscopy.
1833 Utilization of EndoFLIP to Diagnose Achalasia in a Patient With Chronic Dysphagia Previously Attributed to Dysphagia Lusoria
Authors: Hundt Melanie A. , Sharma Prabin , Pourmorady Jonathan , Masoud Amir
Published: October 2019

INTRODUCTION:

Dysphagia lusoria is a rare cause of dysphagia resulting from compression of the esophagus due to an aberrant right subclavian artery. Less than 2% of the population have this anatomic variant and the majority are asymptomatic. An aberrant right subclavian artery may not be clinically significant in a patient with concurrent esophageal pathology.

CASE DESCRIPTION/METHODS:

An 87-year-old woman with a twenty year history of chronic dysphagia complicated by recurrent food impactions presented with poor oral intake and weakness. Previously attributed to paraesophageal hernia, the dysphagia persisted despite partial fundoplication surgery. Prior CTA abdomen was suggestive of dysphagia lusoria, identifying an aberrant origin of the right subclavian artery traversing behind a dilated esophagus with associated mass effect. Achalasia was previously suspected but never confirmed as the patient could not tolerate the manometry procedure. EGD with EndoFLIP revealed a distensibility index of 0.6, a diameter of 5 mm, and a balloon pressure of 29 mm Hg with no appreciable peristalsis, consistent with type I achalasia. EUS revealed an aberrant right subclavian artery without extrinsic esophageal compression. EGD with pneumatic dilatation was performed after which the distensibility index was 6 with a diameter of 12.5 mm. The patient was placed on clear liquids and successfully transitioned to a pureed diet with significant symptomatic improvement. Outpatient follow up is pending.

DISCUSSION:

The EndoFLIP and EUS results confirmed the diagnosis of achalasia while simultaneously showing that the aberrant right subclavian artery represented an incidental finding rather than the true etiology of dysphagia. Moreover, it was the esophageal dilatation caused by achalasia that likely led to the discovery of the previously undetected aberrant subclavian vessel. Given the rarity of clinically significant dysphagia lusoria, it is important to consider alternative diagnoses in the evaluation of dysphagia. Molz G, Burri B. Aberrant subclavian artery (arteria lusoria): Sex differences in the prevalence of various forms of the malformations. Evaluation of 1378 observations. Virch Arch A Pathol Anat Histol 1978;380:303–15.
1844 A Case of Idiopathic Esophageal Ulceration as Initial Presentation of Acquired Immune Deficiency Syndrome
Authors: Din Hassieb , Fasanella Kenneth
Published: October 2019

INTRODUCTION:

Esophageal ulceration (EU) is most frequently caused by gastroesophageal reflux disease. However, immunocompromised individuals are particularly susceptible to EU caused by infections including herpes simplex virus (HSV), cytomegalovirus (CMV), and candida species. Furthermore, patients with acquired immunodeficiency syndrome (AIDS) can also develop idiopathic EU even in the absence of infection.

CASE DESCRIPTION/METHODS:

A 30-year-old male with no significant past medical history presented with 6 months of profound weight loss, odynophagia, dysphagia, and chest pain. He had no history of NSAID use. Symptoms had persisted despite trials of proton pump inhibitors, H2 antagonists, and sucralfate. His physical exam was notable for cachexia and bi-temporal wasting. Esophagogastroduodenoscopy revealed two large hemi-circumferential cratered distal esophageal ulcers separated by a mucosal bridge. Endoscopic ultrasound demonstrated an isoechoic mass in the lower third of the esophagus measuring 1.2 cm in thickness, obliterating the wall layer architecture, along with three enlarged gastro-hepatic lymph nodes. Pathology demonstrated granulation tissue with fibro-inflammatory debris and was negative for malignancy, HSV, and CMV. Fine needle aspiration of one of the enlarged lymph nodes was also negative for malignancy. A contrasted computed tomography scan of the chest, abdomen, and pelvis did not reveal any additional findings. Laboratory evaluation was most notable for worsening leukopenia (WBC count: 3000 cells/μL) and anemia (Hgb: 9.9 g/dL). Further history revealed unprotected sexual encounters with multiple females in the last 10 years. Subsequent workup demonstrated a positive human immunodeficiency virus (HIV) antibody screen with a CD4 count of 44 cells/µL. Patient was ultimately diagnosed with idiopathic EU from AIDS and was initiated on highly active antiretroviral therapy.

DISCUSSION:

While EU is a common complication in patients with AIDS, it is normally associated with infections such as CMV and HSV. Idiopathic EU in these patients are rarer and typically found in those with CD4 cell counts less than 100 cells/µL. Our case was unique in that the patient's development of large EU was his initial presentation of AIDS. In these cases, establishing the correct diagnosis and ruling out malignancy is important as misdiagnosis can significantly alter treatment plan and prognosis. This case further highlights the necessity for HIV testing in patients who present with idiopathic EU.
1850 Intestinal Tuberculosis in an Immunocompetent Patient
Authors: Vaze Reema , Buckshaw Ricky , Malik Anam , Kloska Michal , Aleem Abdul , Stelzer Frederic
Published: October 2019

INTRODUCTION:

Intestinal tuberculosis (TB) is a rare disease in western countries usually only affecting immigrants from endemic areas and those that are immunocompromised. Diagnosis is challenging especially when pulmonary symptoms are absent as it can mimic other abdominal pathologies, notably Crohn’s disease. It is especially important to distinguish between Crohn’s and TB since treatments greatly differ. Intestinal TB favors the small bowel, particular the small ileum due to its affinity for Peyer’s patches. Biopsies positive for acid-fast bacilli confirms the diagnosis. Our case describes an immunocompetent patient diagnosed with intestinal TB that was initially thought to be Crohn’s disease.

CASE DESCRIPTION/METHODS:

A 79-year-old male with a history of TIA, seizure disorder and achalasia presented to the hospital with acute encephalopathy and sepsis. Chest x-ray revealed bilateral infiltrates and the patient was treated for pneumonia. Incidental finding on CT chest, abdomen and pelvis revealed terminal ileitis and an ileocecal valve mass. The patient underwent colonoscopy which showed a terminal ileum and ileal cecal valve lesion with sigmoid stricture and severe left sided diverticulitis. Biopsies were taken that were significant for non-necrotizing granulomas concerning for infectious etiology or Crohn’s disease. The patient was referred to Colorectal Surgery and underwent laparoscopic right hemicolectomy. Surgical pathology revealed extensive granulomas positive for acid-fast bacilli (AFB) secondary to Mycobacterium tuberculosis (TB). Prior to these findings, the patient denied prior TB exposure, travel to TB endemic countries, previous incarceration, pulmonary symptoms, fevers, weight loss, diarrhea, constipation, melena, hematochezia, alcohol or illicit drug use. The patient underwent bronchoscopy with cultures positive for AFB. The patient then began treatment for active TB with a four-drug regimen.

DISCUSSION:

Though rare, intestinal tuberculosis should be kept on the differential when evaluating chronic intestinal diseases. Proper knowledge and anticipation of intestinal manifestations of systemic disease should be mandatory due to the vast differences in treatment. Though diagnosis is difficult in the absence of active symptoms, intestinal tuberculosis should be considered especially in metropolitan areas. Endoscopic evaluation is the mainstay of diagnosis and should be promptly considered to differentiate it from other abdominal pathologies.
1851 The Ever-Mysterious Cyclical Vomiting Syndrome (CVS) and Abdominal Migraine: Recognition and Successful Management Strategies Illustrated by a Case Report
Authors: Yuridullah Ruhin , Yudi Camacho , Botros Youssef , Kapoor Ashima , Melki Gabriel , Baddoura Walid
Published: October 2019

INTRODUCTION:

Cyclical vomiting syndrome (CVS) is a medically and socially disabling, idiopathic disorder characterized by recurrent, stereotypical bouts of vomiting with periods of normal health, occurring in children, adolescents, and recognized in adults. CVS is associated with substantial morbidity. Lack of awareness and recognition leads to tremendous anxiety, cost burden, and delay in diagnosis. Recently updated, Rome IV classification has attempted to highlight the issue to promote early recognition and diagnosis. We present a case of CVS and abdominal migraine in a 27-year-old female whose illness went unrecognized for 8 years and discuss successful management strategies.

CASE DESCRIPTION/METHODS:

A 27-year-old female with an 8-year history of recurrent episodic abdominal pains, nausea, vomiting, incidental superior mesenteric artery syndrome, status post laparoscopic duodenojejunostomy at 24, after which she had an apparent 6-month relief of symptoms, and history of anxiety and depression was seen for persistent diffuse abdominal pain, nausea, and 7-8 daily episodes of emesis for 3 weeks. Family history was significant for migraines in her mother. Since her initial symptoms at the age of 19, she experienced episodes of incapacitating nausea, vomiting, and abdominal pain lasting 3-4 weeks followed by symptom-free periods of 2-3 months. She had visited many hospitals, primary care physicians, psychiatrists, and gastroenterologists, and undergone repeated work-ups from basic to complex. Treatment with SSIRs, anti-emetics, valproic acid and even marijuana showed no or minimal benefit. Following thorough history and obtainment of records from other institutions, she was diagnosis and started on a combination of amitriptyline, propranolol, and Co-enzyme Q/L-Carnitine. She has been followed by monthly phone calls for about 1-year, remains symptom-free, and compliant with the regimen.

DISCUSSION:

Cyclic vomiting syndrome (CVS) is characterized by recurrent bouts of nausea and vomiting with periods of normal health. The pathogenesis is multifactorial, with multiple genetic, autonomic, and environmental factors. Often a great delay in diagnosis, on average 2.6 years in children and 8 years in adults leads to unnecessary testing and cumbersome procedures. In the case of our patient, her illness was unrecognized for many years and her symptoms often dismissed, pushing her into anxiety and depression. A multidisciplinary approach as well as prophylactic and abortive pharmacotherapy is needed to address the issue.
1861 Duodenal Gangliocytic Paraganglioma in Patient With Rectal Adenocarcinoma
Authors: Villavicencio Jaimy , Disiena Michael , Elkhattib Ismail , Birk John
Published: October 2019

INTRODUCTION:

Gangliocytic paragangliomas are a rare subclass of neuroendocrine tumors that usually appear in the periampullary region of duodenum. They are generally benign, although may have potential for metastases depending on size and extension. They most commonly present with bleeding or abdominal pain, but cases with obstructive jaundice and pancreatitis have also been reported. They are often misdiagnosed as GISTs or other neoplasms, but with histologic examination, an accurate diagnosis can be reached. However, intraoperative diagnosis with FNA and frozen section analysis are often inaccurate and could affect surgical decision.

CASE DESCRIPTION/METHODS:

62-year-old male with past medical history of diverticulitis, internal hemorrhoids, and iron deficiency anemia presented with syncope and gastrointestinal bleeding. During evaluation with colonoscopy, a mass was found in the rectum, which was later confirmed to be an adenocarcinoma. An FDG-avid duodenal segment was incidentally found while undergoing workup with PET-scan. He had neoadjuvant chemoradiation, with resection of rectal cancer and temporal ileostomy. Biopsy of duodenum with endoscopic ultrasound revealed normal duodenal mucosa on 2 separate occasions. Ultimately, the duodenal tumor was excised via exploratory laparotomy. Intraoperative frozen biopsy of mass revealed a GIST and a Whipple procedure was performed due to proximity to ampulla. Final pathology report revealed a gangliocytic paraganglioma, after staining positive with synaptophysin (as well as S-100 and neuron specific enolase) and negative for antibody to CD117, which is a sensitive marker for GISTs.

DISCUSSION:

Duodenal gangliocytic paragangliomas remain to be rare entities. There is yet no clear consensus in regards to appropriate workup, treatment or follow-up, especially in patients with metastases or concurrent adenocarcinoma. It is uncertain if coexistence with a rectal adenocarcinoma (as seen in this case) was coincidental or due to similar pathogenesis. Diagnosis with FNA and frozen section biopsies can be useful, but are often inaccurate. The success largely relies on the operator and clinical suspicion, but it is especially hard when there are no symptoms or relevant history. The recommended management is margin-free resection endoscopically, with local surgical excision or Whipple procedure. Studies have shown that some molecular markers can predict malignant potential. Yet, whether they are useful for management or surveillance has not been determined.
1862 Novel Endoscopic Repair of a Percutaneous Endoscopic Gastrostomy Tube Malpositioned Through the Transverse Colon
Authors: Campbell John P. , Klein Daniel , Gupta Vipin
Published: October 2019

INTRODUCTION:

Malpositioning of a PEG tube on placement has been well documented in the medical literature. This case outlines a novel approach to repairing a malpositioned PEG tube in a patient that was not a surgical candidate.

CASE DESCRIPTION/METHODS:

This is a 60-year-old male with a past medical history of gastroparesis, end-stage renal disease, and diabetes mellitus who was admitted for influenza and severe acidosis. Soon after admission he underwent cardiac arrest and had return of spontaneous circulation after 20 minutes of resuscitation. Following a prolonged hospital course, tracheostomy and PEG tube placement with Soldinger technique were performed. Over the subsequent days, he experienced melenic stools and declining hematocrit. Colonoscopy showed a foreign body suspicious for a feeding tube crossing the transverse colon. He was found to not be a surgical candidate due to his comorbidities, and a contrast enema showed no extravasation of contrast. Repeat endoscopy was therefore performed to attempt correction. Our novel approach began with colonoscopy. Once the foreign body was visualized, the tubing was cut from the outside and pulled by forceps into the lumen of the transverse colon. Hemostatic clips were applied to the colonic mucosa to close the first perforation. The team then transitioned to gastroscopy. The PEG tube hub was visualized in the stomach and removed. Additional clips were used to close this gastric perforation. The team then turned attention to the second colonic perforation. Once located, clips were used to close this final perforation. Subsequent plain films did not show free air, and abdominal exam remained generally benign. Upper GI series was without evidence of extra-luminal contrast material. CT showed no abscess or fluid collection. He was soon able to be fed through a nasoduodenal tube. Later, he was weaned from the ventilator and able to resume a solid diet without complication.

DISCUSSION:

This case was unique in its endoscopic approach to repairing a malpositioned PEG tube in a patient that could not be taken to surgery. Without this novel endoscopic approach, this patient would have likely experienced significantly increased morbidity. Although these methods have not been extensively documented in the literature, this approach may be warranted in some patients who could not proceed to traditional surgery. We hope to start discussion about future research into the area of endoscopic repair of a malpositioned PEG tube.
1870 Chest Tube Protrusion Into the Gastric Cavity Resulting in Biliary Drainage
Authors: Haddad Ibrahim , El Kurdi Bara , Aasen Tyler , El Iskandarani Mahmoud , Babar Sumbal , Alomari Mohammad , Al Momani Laith , Goenka Puneet
Published: October 2019

INTRODUCTION:

Biliary drainage through a chest tube is a rare clinical finding that might be caused by Biliothorax or inadvertent penetration of the chest tube to the esophagus or the proximal stomach wall. We present a 63-year-old male patient who underwent Ivor Lewis esophagogastrectomy with his post procedural course complicated by chest tube migration and protrusion into the stomach cavity through gastropleural fistula.

CASE DESCRIPTION/METHODS:

A 63-year-old male patient who underwent Ivor Lewis esophagogastrectomy for distal esophageal adenocarcinoma, his clinical course was complicated by left sided pleural effusion and pneumothorax for which a chest tube was inserted. The patient clinical condition was stabilized and was discharged to an inpatient rehabilitation facility with the chest tube. Twenty days after discharge, the patient started to have bilious drainage through his chest tube again. He was admitted to hospital, imaging showed recurrent left pleural effusion. EGD was performed and showed chest tube protrusion into the stomach cavity through a gastropleural fistulas near the gastroesophageal junction. The chest tube was retracted and the gastropleural fistula was closed with over-the-scope clips. Bilious output stopped and the chest tube was removed with no further leakage.

DISCUSSION:

Biliary drainage through a chest tube is a rare clinical entity. It is highly suggestive of an esophageal leakage from a procedural complication. Gastropleural fistulae are rare and often occur as a complication of gastroesophageal surgery. When present, hardware, such as a chest tube, can be trapped into them resulting in various presentations. Endoscopic closure with over-the-scope clips may represent an effective and less invasive technique to close post procedural fistula tracts.
1883 A Surprising Biopsy Result: Primary GI Amyloidosis
Authors: Brindise Elizabeth , Tathineni Praveena , Venkataraman Subramanian
Published: October 2019

INTRODUCTION:

Amyloidosis is the deposition of insoluble extracellular protein fragments. Gastrointestinal (GI) amyloidosis often presents with abdominal pain, weight loss, diarrhea and GI tract bleeding. Diagnosis is confirmed with congo red stain showing green birefringence under polarized light. Treatment differs for each type of amyloidosis; thus, accurate diagnosis is crucial for successful treatment. We present a case of primary GI amyloidosis presenting with new onset microcytic anemia.

CASE DESCRIPTION/METHODS:

A 73-year-old African American male with past medical history of hypertension, hyperlipidemia and erythrocytosis secondary to obstructive sleep apnea was being seen for a routine follow up by his hematologist. The erythrocytosis was previously evaluated with JAK2 and EPO testing; both negative. He was being treated with periodic phlebotomies, remaining asymptomatic. However, on this particular office visit he was found to have a new microcytic anemia, for which gastrointestinal workup was recommended. Upon evaluation by the gastroenterologist, esophagogastroduodenoscopy (EGD) and colonoscopy were performed. The EGD showed a non-obstructing Schatzki ring, erosive gastritis, a gastric ulcer at the pre-pyloric region, duodenitis and multiple superficial duodenal erosions. The colonoscopy showed a polyp in the cecum and descending colon and diverticulosis. Biopsies were taken during the procedures and returned with amyloid depositions, consistent with GI amyloidosis in the duodenum, stomach and descending colon. A few weeks later, the patient developed rectal bleeding and passage of clots. Repeat colonoscopy was done which showed diffuse large ulcerations in the sigmoid and descending colon. Again, pathology confirmed amyloid depositions in the GI mucosa. Given these surprising findings, his hematologist performed a bone marrow biopsy which showed normocellular marrow with trilineage hematopoiesis, negative for malignancy. Myeloma FISH panel was positive for 11.14 translocation. The patient was diagnosed with light chain myeloma with amyloidosis (AL subtype) involving the GI tract for which steroids and chemotherapy were initiated.

DISCUSSION:

Our case discusses a rare diagnosis of primary GI amyloidosis. This patient is unique because GI amyloidosis was his primary presentation without any cardiovascular or renal manifestation. Although amyloidosis is rare, it is important to have a high index of suspicion when evaluating new onset anemia of unknown origin.
1884 Migration of Embolization Coil in a Crohn’s Patient With NSAID-Induced Peptic Ulcer Disease
Authors: Mandiga Pujyitha , Patel Kruti , Miller Justin
Published: October 2019

INTRODUCTION:

Peptic ulcer-related bleeding has a high mortality rate if not controlled. If endoscopic interventions fail, interventional radiology or surgical intervention is often considered. We report a case of rare complication of Transcatheter Arterial Embolization (TAE) for bleeding duodenal ulcer in a patient with Crohn’s Disease.

CASE DESCRIPTION/METHODS:

A 69-year-old female with a previous medical history of Crohn's colitis (on prednisone taper for active Crohn’s disease/pending initiation of biologic therapy) presented to the emergency department for generalized weakness, nausea, non-bloody, non-bilious emesis and melena. No prior history of gastrointestinal bleeding, antiplatelet or anticoagulation use was reported. Medications includes: Prednisone 20mg and Naproxen 400mg (BID or TID). Hemoglobin was 6.0 (11.0-16.2 g/dL), BUN 46 (8-26mg/dL), Cr 1.54 (0.44 – 1.00 mg/dL). Upper GI bleed was suspected with the initiation of Pantoprazole 80mg IV, 3 units of pRBC and Intravenous fluids. Endoscopy performed post-resuscitation revealed LA Grade D esophagitis, large non-bleeding duodenal bulb ulcer with extension into the sweep. No endoscopic therapy was performed. Twenty hours later, the patient became hemodynamically unstable requiring massive transfusion. As ulcer was not amenable to endoscopic therapy, Interventional radiology was consulted who TAE with the placement of two coils in the gastroduodenal artery (GDA). The patient tolerated the procedure well without any recurrence of bleeding. A follow-up endoscopy four weeks later, showed improvement in ulceration with only a 3-4 mm area of non-bleeding, healing ulcer with a coil protruding from ulcer site. The coil was left in place without any manipulation to the area. The patient was advised to discontinue NSAIDs and continue Pantoprazole 40 mg BID. In the interim, the patient was started on Vedolizumab (Entyvio) with improvement in CRP and abdominal pain.

DISCUSSION:

Embolization of GDA is safe and effective in patients with high surgical risk. Complications such as duodenal ischemia, hepatic artery embolization, duodenal stenosis do exist. Migration/Erosion of coil into lumen can occur, especially in a patient with active Crohn’s disease. Ulceration surrounding the coil can occur with a consequence of bleeding, which would require surgical intervention if endoscopic hemostasis is unable to be achieved.
1887 Don’t Stop at the Colon! A Rare Case of Strongyloides Hyperinfection Diagnosed on Esophagogastroduodenoscopy
Authors: Dalal Shaman , Sheth Niyati , Jain Alok
Published: October 2019

INTRODUCTION:

Strongyloides stercoralis (SS) endemic to the tropics, is uncommon in the US. Symptoms from SS infection can mimic Irritable Bowel Syndrome (IBS). Immunocompromised individuals may present with fatal systemic ‘hyperinfections’ where SS larvae enter the bloodstream and bring enteral bacteria with it. Current literature recommends the use of endoscopy with biopsy to confirm diagnosis and begin prompt treatment to prevent further complications.

CASE DESCRIPTION/METHODS:

A 46-year-old woman with Rheumatoid Arthritis managed with prednisone and Rituximab presented for chronic abdominal pain and diarrhea reportedly from IBS. Past medical history was significant for recurrent hospital admissions for gram negative meningitis attributed to her immunocompromised state. She was treated with Ceftriaxone empirically each time. As part of her IBS workup, she underwent out-patient diagnostic Esophagogastroduodenoscopy (EGD) and Colonoscopy. The Colonoscopy was unremarkable. The EGD showed diffuse white villi in the second part of the duodenum. Biopsy revealed inflammation with presence of many SS larvae and eosinophils. A unifying diagnosis of SS hyperinfection causing recurrent gram negative meningitis was thus made. The patient was treated with Ivermectin and Albendazole. Surveillance EGD and Colonoscopy with random biopsies showed absence of SS. She reported complete resolution of her symptoms.

DISCUSSION:

‘Auto-infected’ SS larvae in the duodenum can transform into adult worms which reside in the colon and are known to mimic IBS. In immunocompromised hosts larvae can also enter bloodstream by transmural migration of the duodenum causing hyperinfection. Literature from regions endemic to SS suggest that enteral bacteria may accompany the larvae during this migration causing gram-negative septicemia and meningitis. Diagnosing SS can be challenging. Stool studies have poor diagnostic sensitivity. Endoscopy with biopsy confirming presence of SS larvae as seen in our patient continues to give the highest yield for diagnosis and prompt treatment to prevent fatal outcomes. A variety of endoscopic findings including duodenal white villi are documented but no pathognomonic finding is established for which more cases need to be reported. While a large burden of the adult worms reside in the colon causing IBS like symptoms, SS larvae reside in the crypts of duodenal mucosa. If SS hyperinfection is suspected, we strongly recommend to not stop the investigation at a diagnostic Colonoscopy but also perform an EGD.
1894 Gastrointestinal Post-Transplant Lymphoproliferative Disorder (PTLD) With Rapidly Forming Characteristic Lesions After Heart Transplantation: A Case Report
Authors: Azab Mohamed , Mosier Evan , Lewis Terence D. , Wright Andrew P.
Published: October 2019

INTRODUCTION:

Post-transplantation lymphoproliferative disorders (PTLDs) are the second most common neoplasms in adult transplant recipients. Epstein-Barr virus infection in the setting of immunosuppressive therapy is implicated etiologically in most cases. More than half of PTLD cases present with extra-nodal involvement including the GI tract. Few reports have described the endoscopic findings. We present a case of rapidly progressive PTLD involving the GI tract with gross lesions that developed less than 2 months after a macroscopically normal upper and lower endoscopy.

CASE DESCRIPTION/METHODS:

A 37-year-old female with history of orthotopic heart transplant 3 months prior for transposition of the great arteries was admitted to the hospital with 3 weeks of non-bloody diarrhea. Her immunosuppressive regimen included tacrolimus, mycophenolate and prednisone. Extensive serologic and fecal testing was performed with no evidence of systemic CMV, EBV, HSV (serum PCR), clostridium difficile, or other bacterial intestinal infection. She underwent diagnostic upper and lower endoscopy with no grossly visible lesions. Random colon biopsies demonstrated increased lamina propria eosinophils and eosinophilic crypt abscesses suggestive of drug-effect. A presumptive diagnosis of mycophenolate induced colitis was made. Symptoms resolved however during her hospitalization and she was continued on mycophenolate. She presented 6 weeks later with 3 weeks of recurrent non-bloody diarrhea. Repeat serologic and fecal testing revealed EBV and CMV viremia. CT abdomen and pelvis with IV contrast was unremarkable. Repeat upper and lower endoscopy revealed multiple new ulcerated nodular lesions 1 cm in size (Figures 1 and 2) in the stomach, duodenum, terminal ileum and entire colon. Biopsies showed monomorphic PTLD, diffuse large B-cell type, with EBV positive staining.

DISCUSSION:

PTLD can be isolated to the gastrointestinal tract in immunocompromised post-transplant patients. Endoscopy with biopsy is required to establish the diagnosis. When there is high suspicion for PTLD, consideration should be given for repeat endoscopy even with recent normal examination as macroscopic and microscopic findings may develop rapidly.
1899 Bronchial Aspiration of Capsule Endoscopy: A Rare but Potentially Fatal Complication
Authors: Rutazaana Darius , Nawaz Arif
Published: October 2019

INTRODUCTION:

Video capsule endoscopy (VCE) is increasingly being used in the diagnosis of small bowel disorders and the evaluation of suspected small bowel bleeding in adults. VCE is considered a safe procedure with no attributable deaths. Clinically significant complications include symptomatic capsule retention and aspiration that occur in less than 2% of examinations.

CASE DESCRIPTION/METHODS:

A 67-year-old male with history of developmental delay and with no history of swallowing disorder or stroke was initially admitted to the hospital with severe symptomatic anemia. His hemoglobin was 7.1g/dl. Anemia work up revealed serum iron level of <10g/dl and a ferritin level of 4.30. He underwent upper GI endoscopy and colonoscopy with findings of a short segment Barrett’s esophagus and small non-bleeding hemorrhoids. He was then scheduled an outpatient VCE. He was given the capsule and asked to swallow it. He initially had some difficulty in swallowing it but then took a big gulp and apparently swallowed it. Immediately upon swallowing, he started experiencing difficulty breathing. Nursing staff present immediately checked his oxygen saturation and noted a transient drop which corrected with minimal oxygen supplementation. An X-ray was immediately ordered and the monitor activated. Images suggested ingestion into the bronchus and a chest X-ray confirmed presence of a pill camera overlying the right main stem bronchus. He underwent an emergent flexible bronchoscopy with successful extraction of the capsule. This was followed by endoscopy assisted capsule insertion into his duodenum.He tolerated the procedure well.

DISCUSSION:

VCE is increasingly being used to provide diagnostic imaging of the small intestines, an anatomic site that is peculiarly difficult to visualize. Suspected small bowel bleeding and tumors of the small bowel are some of the common indications of VCE.Capsule aspiration although a rare complication with VCE can be life threatening. Early detection with emergent timely retrieval of the capsule is recommended. In order to prevent such complications and to be able to intervene expeditiously, it is recommended that VCE should be administered in an office with oxygen and where other resuscitative facilities are available. In conclusion, though rare, capsule aspiration is a serious complication of VCE and physicians should pay attention to patients who have any delay in capsule ingestion and if possible confirm passage of the capsule endoscope into the stomach before the patient leaves the clinic.
1906 Double Pylorus: Case Report of Atypical Presentation
Authors: Orpiano Christopher L. , Kang Gurjeet , Quinn Michael , Venu Lakshminarasimhan , Staffetti Joseph
Published: October 2019

INTRODUCTION:

Double pylorus is a rare endoscopic finding that has been reported in 0.001% to 0.4% of upper gastrointestinal endoscopies, consisting of a gastroduodenal fistula extending from the prepyloric gastric antrum to the duodenal bulb through an accessory channel. In the majority of cases, it is a complication when peptic ulcers erode and create a fistula between the duodenal bulb and the distal stomach. It usually presents on the lessor curvature of the gastric antrum and on a superior wall of the duodenal bulb. It is commonly an endoscopic finding, since clinical presentation is similar to other peptic diseases.

CASE DESCRIPTION/METHODS:

The patient was a 62-year-old female presented to the emergency room for evaluation of intractable nausea and vomiting. The patient reported sudden onset of symptoms day prior, with multiple episodes of brown-colored liquid emesis. Patient denied any associated abdominal pain, no postprandial association with food. CT showed significant mucosal thickening of the gastric antrum to proximal duodenum, resulting in severe dilation of the stomach with air fluid level. Nasogastric tube was then placed for decompression and serial KUB showed adequate position and non-obstructive bowel gas pattern. An esophagogastroduodenoscopy revealed moderate gastritis and antral duodenal fistula, an accessory channel was noted on the lesser curvature side and once engaged was able to be passed with the endoscope. Pathology returned reactive mucosal changes suggestive of focal erosions, Helicobacter Pylori returned negative.

DISCUSSION:

The majority of reported cases of double pylorus are acquired and are attributed to complications of ulcers at the antrum-pyloric area or at the duodenal bulb. Acquired double pylorus typically present symptomatic with chronic upper abdominal pain, vomiting, dyspepsia, or upper gastrointestinal bleeding. Patients often have a long history of treatment with NSAIDs or corticosteroids, which should prompt an investigation for Helicobacter pylori and eventual treatment if found positive. Medications for the reduction of peptic acid should be taken and ulcerogenic medications should be avoided. The majority of patients respond well to medical treatment, according to a retrospective follow-up study in patients treated with H2 receptor antagonist or proton pump inhibitor after the diagnosis of acquired double pylorus, the fistula remained open in the majority of patients (64%), fused with normal pylorus in 27% of patients and closed only in 9% of cases.