bluuebunny/crossref_metadata_2025 huggingface dataset:
3062 Strongyloides stercoralis: A Rare Etiology of Infectious Colitis
Authors: Then Eric O. , Hernandez Kimberly , Ofosu Andrew , Gayam Vijay , Bengualid Victoria , Gaduputi Vinaya
Published: October 2019

INTRODUCTION:

Strongyloides colitis is a rare parasitic infection caused by the nematode (roundworm) Strongyloides Sterocalis. This infection is endemic to tropical and subtropical regions with poor sanitation, but it is also prevalent in rural regions of the United States. Here, we present a rare case of strongyloides colitis in a patient with human immunodeficiency virus.

CASE DESCRIPTION/METHODS:

The patient is a 40-year-old male with no significant past medical history who presented to the emergency department (ED) with progressive diffuse abdominal pain. The pain previously occurred with meals, but then became constant. Notable laboratory workup included a hemoglobin of 8.7 gm/dL and increased eosinophil count of 0.86 103/uL (ref range 0.04-0.54). The patient also tested positive for human immunodeficiency virus. A computed tomography scan of the abdomen showed a thickened colon from the level of the splenic flexure to the rectum indicating colitis as a possible diagnosis. Colonoscopy was then performed and showed diffuse severely ulcerated mucosa that oozed. In addition, there were prominent edematous folds with superimposed inflamed mucosa without the presence of discernible mass lesions. Intravenous antibiotics were started and there was symptomatic improvement leading to the patient's discharge. Three days post-discharge, the colonic biopsies returned showing parasitic larvae in the lamina propria of the colonic mucosa suggestive of Strongyloides species. The patient was contacted and stated he would return for follow-up to his doctor for treatment.

DISCUSSION:

Strongyloides colitis is an easily treated infection, however if untreated can have a high mortality rate. This is especially true for immunocompromised patients and those given immunosuppressive agents, such as those with inflammatory bowel disease (IBD). Considering this infection can present clinically and morphologically similar to IBD, it is important to differentiate the two before steroids and other immunosuppressive agents are administered. The feared complication of this infection is dissemination via autoinfection. Autoinfection is characterized by penetration of the intestinal mucosa by the larvae where they can then travel to the lungs causing pneumonia and acute respiratory distress syndrome. The larvae can also travel to various other organs causing multi-organ failure and death. This, however, can be avoided with proper diagnosis and successful treatment with Ivermectin or Albendazole.
3063 Colon Cancer in 41-Year-Old With Presenting Symptom of New Onset Ascites Masked by History of Alcoholism
Authors: McDonald Emmanuel , Skrove Jamie L. , Sobrado Javier , Mohan Karthik
Published: October 2019

INTRODUCTION:

Colorectal cancer remains one of the leading causes of cancer-related deaths in the United States to this day. What was primarily seen in the 50+ population, is now being diagnosed more frequently in younger adults, with the proportion of cases diagnosed in individuals younger than age 50 increasing from 6% in 1990 to 11% in 2013. 72% of these cases occur in patients in their 40s. It is important not to dismiss the possibility of this diagnosis in a differentially solely based on patient age, especially when symptoms may be explained away by other more obvious diagnoses.

CASE DESCRIPTION/METHODS:

A 41 yr old male with history of hypertension, reflux, 30 pack year smoking history and 30 years of daily vodka intake presented with 10 day history of worsening abdominal pain, distention and constipation. Abdominal CT showed mild/moderate ascites, unremarkable spleen and liver, and no identifiable masses. Paracentesis was performed and 2.3 liters of ascitic fluid was removed. SAAG was calculated at <1.1 and BF protein >2.5, which was not indicative of alcoholic hepatitis or portal hypertension. Acute hepatitis panel was negative. MELD score was 8 and liver enzymes were WNL. Liver ultrasound was performed and ruled out portal vein thrombosis. Primary team was convinced the ascites was from the history of alcoholism and convinced patient of the same. Liver biopsy was ordered, however after discussing the case with the primary team and the patient, EGD and colonoscopy was finally agreed upon with much reluctance. EGD showed gastritis. Colonoscopy showed a flat, hardened area in the cecum that resembled colitis visually. Biopsies were taken and resulted as adenocarcinoma.

DISCUSSION:

The classic triad for cecal cancer of right sided pain, a palpable mass, and microcytic anemia were not seen in this patient; and most cases of early colon cancer present with no symptoms at all. The fact that this patient had ascites and generalized abdominal pain that brought him to the hospital was a blessing so to speak. If the opportunity had been squandered to get the correct diagnosis due to ease of another more reasonable explanation, the results would have been injurious. This case is an important lesson that physicians cannot dismiss a full differential just because there may be a more plausible explanation. If the workup had stopped at the liver in this patient, the diagnosis of colon cancer in a 41 year old young man would have been missed, and that would have been detrimental.
3065 Foreign Body Colonic Perforation: Considerations Beyond the Colon
Authors: Bommena Shoma , Mann Sarabdeep , Seetharam Anil
Published: October 2019

INTRODUCTION:

Toothpick ingestion may cause gastrointestinal tract perforation; associated injury of extracolonic vasculature or soft-tissue is rarely reported. We present a case of toothpick related sigmoid colon perforation and associated internal iliac artery injury requiring sigmoid colon resection.

CASE DESCRIPTION/METHODS:

A 44-year-old male with Marfan syndrome and COPD presented to our hospital with progressive right hip pain for a week. On physical exam he was febrile, tachycardic, and had tenderness of his right lateral thigh. He was found to have a leukocytosis of 18k, as well as an elevated ESR and CRP. Blood cultures grew Bacteriodes. An abdominal CT showed a right psoas abscess and a thin, dense linear structure extending from the distal sigmoid colon, through the right internal iliac artery, and terminating just anteromedial to the right sacroiliac joint. IV antibiotics were initiated. Interventional radiology performed a CT guided abscess drainage. GI was consulted as there was suggestion of a sigmoid fistula/foreign body on imaging. The patient had no recollection of ingestion of a foreign body. Flexible sigmoidoscopy showed a foreign body traversing the wall of the distal sigmoid colon (Figure 1). It was not removed endoscopically due to perforation through the colonic wall, as it was unclear what was on the extra luminal side of the object. Colorectal surgery was consulted and he urgently underwent a hand-assisted laparoscopic partial sigmoid resection on the same day. Intraoperative findings showed a perforation of the distal sigmoid colon due to a toothpick with associated injury to internal iliac artery. The affected portion of the sigmoid colon with the toothpick was removed laparoscopically, after which there was noted to be pulsatile bleeding from the internal iliac artery that resolved with manual pressure for 20 minutes. The iliac artery was subsequently repaired and a primary colonic anastomosis was performed. Gross operative specimen is shown in Figure 2. Post-operative course was uncomplicated and the patient was discharged home in stable condition.

DISCUSSION:

Ingestion of sharp pointed objects such as toothpicks pose a significant risk of organ injury. We demonstrate a case of an ingested toothpick resulting in a perforation through the sigmoid colon and the internal iliac artery, presenting initially as a psoas abscess. This was successfully treated surgically and the patient did well post-operatively.
3084 A Case of CMV Colitis: Both a Cause and Consequence of Acute Renal Allograft Rejection
Authors: Radow Mark
Published: October 2019

INTRODUCTION:

Cytomegalovirus is an extremely common pathogen that usually causes a mild, self-limiting disease in the immunocompetent host. The risk of active CMV disease increases in states of immunosuppression (AIDS, transplant recipients, cancer, IBD, use of immunosuppressive agents). CMV infection in transplant recipients has a predilection for the gastrointestinal tract.

CASE DESCRIPTION/METHODS:

A 46 yo African American male with history renal transplant in 2002 presented to the hospital for worsening creatinine. He was previously doing well on immunosuppression with sirolimus, cyclosporine, and prednisone. His baseline creatinine was 2.2-2.6 mg/dL. On admission his Cr was 5.8. He underwent a renal biopsy that was suspicious for antibody-mediated rejection. He received high dose IV steroids, plasmapheresis, and IVIG. His Cr improved to 4 and he was discharged on tacrolimus, mycophenolate, and a tapering prednisone dose. He returned to the hospital 3 weeks later with dyspnea and peripheral edema. He also had 2 episodes of hematochezia the day prior. His Cr increased to 7.2 and his hemoglobin dropped from 8.9 g/dL to 6.9. He was started on dialysis. His hemoglobin initially improved with a transfusion but 3 days later dropped to 6.9. GI was consulted. Colonoscopy revealed a 7 × 7 mm ulcer at the ileocecal valve. Biopsies confirmed CMV colitis. He was evaluated by infectious disease for treatment.

DISCUSSION:

CMV infection of the GI tract is relatively common in organ transplant recipients and can involve the upper or lower GI tract. It can result in mucosal injury, ulcerations, hemorrhage, GI dysmotility, or perforations. CMV colitis can present with fever, abdominal pain, diarrhea, hematochezia, toxic megacolon, or perforation. Lower GI bleeding is the most common initial presentation. Endoscopic findings of CMV colitis are categorized into 3 groups: well-demarcated ulcers, diffuse infiltrative ulcers, and pseudomembranous patterns. Sometimes hemorrhagic colitis is seen with multiple punctuate lesions. CMV reactivation can be elicited by high intensity immunosuppression and disease can lead to allograft dysfunction and rejection. Patients at risk for CMV infection should be started on antiviral prophylaxis. With symptoms of disease, a prompt diagnosis is necessary in order to start antiviral therapy with IV ganciclovir or oral valganciclovir. A delay in treatment can result in high morbidity and mortality and therefore clinicians need to have a high index of suspicion.
3087 Combined Endoscopic and Surgical Management of Small Bowel Polyposis in a Patient With Peutz-Jeghers Syndrome
Authors: Li Feng , Liska David , Cauley Christy , Dionigi Beatrice , Mankaney Gautam , Kalady Matthew F. , Church James M. , Burke Carol A. , Bhatt Amit
Published: October 2019

INTRODUCTION:

A 55-year-old male with history of Peutz-Jeghers syndrome was referred for a colonoscopy for management of a large ileal polyp. Surgical history was notable for two laparatomies for small bowel obstructions in the setting of intussusception as well as multiple enterotomies for removal of polyps.

CASE DESCRIPTION/METHODS:

Colonoscopy confirmed a polypoid mass in the distal ileum that was partially obstructing. Endoscopic submucosal dissection of the polyp stalk was performed but revealed two feeding arteries as well as a thick muscular band, concerning for muscularis propria, that precluded further safe dissection. Hemoclips were placed on the feeding arteries in an attempt to cause necrosis of the lesion. After discharge the patient developed hematochezia. Repeat colonoscopy did not show any ongoing bleeding but the mass appeared to be necrotic. Repeat colonoscopy was planned in the operating room to evaluate the mass. If the necrosis was not complete, dissection of the stalk would be re-attempted with plans to convert to surgical resection if needed. On endoscopy, the mass appeared to have revitalized. Another attempt at submucosal dissection of the polyp stalk was performed. However as the area had already been dissected through, the submucosal plane was not easily identified in the stalk and did not feel that it was safe to continue the submucosal dissection. Subsequently, the patient was converted to surgical resection of the ileal polyp, which also revealed multiple polyps more proximally throughout the small bowel. The bowel resection included the initial large polyp and another large polyp at a prior ileal anastomosis that could not be removed without a resection. Multiple other polyps were removed via enterotomies. To clear the remaining small bowel of residual polyps, we performed a clean sweep. A pediatric colonoscope was introduced orally and the scope was able to be advanced distally to the ileal anastomosis by plicating the bowel over the scope. Multiple further polypectomies were then performed using standard endoscopic mucosal resection technique. On 3 month follow up MR enterography, there were no convincing polyps identified in the entire small bowel.

DISCUSSION:

This case demonstrates the importance of a multi-disciplinary approach to the management of this patient's polyposis. The combination of endoscopic and surgical approach allowed for effective management of both the large ileal polyp as well as his overall polyp burden.

Watch the video: http://bit.ly/2JWHRA2
3089 Orifice to Orifice Evaluation, in a Single Exam
Authors: Nakshabendi Rahman , Klair Jagpal S. , Hasan Yazan , Gerke Henning , El Abiad Rami
Published: October 2019

INTRODUCTION:

We present a case of a middle age Caucasian male with Peutz-Jeghers syndrome who underwent an antegrade double balloon enteroscopy (DBE) for surveillance of a known small bowel polyps. He has a history of right hemicolectomy for a large polyp and subsequent partial small bowel resection for intussusception of a jejunal polyp. He had a DBE a year ago which revealed several small bowel polyps, the larger ones requiring therapeutic intervention. We show a video demonstrating feasibility of complete entero-colonoscopy dictated by necessity.

CASE DESCRIPTION/METHODS:

A 55-year-old Caucasian male with Peutz-Jeghers syndrome presented for his surveillance antegrade DBE. He has history of right hemicolectomy & partial jejunal resection due to intussusception deemed secondary to a large hamartomatous polyp. He has been getting EGD, Colonoscopy and antegrade DBE every 2 years given his history of multiple large hamartomatous polyps. His vital signs, physical examination and lab work were unremarkable.

DISCUSSION:

This patient underwent antegrade DBE with a therapeutic double-balloon enteroscope (Fujinon EN-450 T5) using push and pull maneuver, under general anesthesia and utilizing CO2 for insufflation. A stiffening device (Zutron medical) was used during portions of the procedure to help prevent loop formation. Around the distal jejunum, the stiffening device snapped within the biopsy channel at the boot of the insertion tube of the enteroscope. Given that a significant amount of time has been already invested in the procedure an attempt at reaching the anus was pursued with success. The stiffening device was pushed out of the channel using a biopsy forceps and the procedure was resumed. Multiple polyps (atleast 30) were observed in the small bowel ranging in size from 4-25 mm, some of which were oozing. The oozing polyps and those larger than 10 mm (total 6) were resected. The procedure was completed with no adverse events. The patient's oral cavity was cleaned using hydrogen peroxide swab before he was extubated and sent to recovery. The patient experienced no infection related complication, bleeding, perforation or pancreatitis.

CONCLUSION:

1. It is feasible and safe to perform through and through entero-colonoscopy in specific scenarios. 2. Panendoscopy in one encounter may not always be achievable in patients without a history of bowel resection. 3. Advancing the enteroscopy outside the anus may be considered to clear an obstructed biopsy channel as an option to salvage a long procedure.

Watch the video: http://bit.ly/2XTDKhY
3094 Esophageal Strictures After Ingestion of Picosulfate Powder for Colonoscopy
Authors: Kim Seongmin , Kwon Hyeonwoo , Lee Jun Su , Cho Byungha , Choi Jongwook , Park Seon Mee
Published: October 2019

INTRODUCTION:

Picosulfate solution is widely used as a small volume bowel cleansing agent considered to be effective and relatively safe.

CASE DESCRIPTION/METHODS:

A 75 - year - old woman came to our hospital with severe neck pain that occurs when she swallows food. A week before our hospital visiting, she had scheduled the EGD and colonoscopy for a health checkup. At the time of EGD, there was white exudates and hemorrhagic spots in the esophagus. But, she had any pain at that time. After 1 week she felt a severe sore throat, visited otolaryngologist, but she was told there was nothing wrong. Despite of medication, she continued to suffer severe pain and she came to our emergency room and received otolaryngologist consultation. However, she was told that she had no particular abnormal findings. She underwent an EGD to examine the cause of the neck pain. The EGD showed multiple superficial ulcers and yellowish exudates throughout the esophagus (Figure 1). We had a biopsy in the esophagus. The result was candidiasis. One week later, she had difficulty in swallowing, and she had another EGD. The esophageal lumen was narrowed at the position of upper incisor (UI) 20 ∼ 30 cm and multiple ulcers were scattered and the endoscope could not pass to the distal side of the esophagus (Figure 2). We investigated her medication history to find out why she had the esophageal strictures. She was being treated for diabetes and atrial fibrillation 20 years ago, and we found she had taken picosulfate powder for colonoscopy a week ago. She mistakenly took the picosulfate powder first, drank the water later. She felt a little uncomfortable with the epigastric area, but she thought it was nothing. During her hospital stay, she was treated conservatively, including fasting, antibiotics, and parenteral nutritional support. After her symptoms improved, she was discharged. About a month later, she came to the outpatient clinic because of dysphagia for solid food. EGD showed esophageal stricture at UI 25 cm and passed through the site using a ultrathin scope. The narrowed area of the UI 30 cm was not able to pass through the endoscope (Figure 3). Using a guide wire, a 10 cm full covered metal stent was inserted through the scope.

DISCUSSION:

We reported a case of esophageal ulcer and stricture caused by a picosulfate power that the patient took accidentally. When picosulfate powder is used as a bowel cleansing agent, patient should be educated to take after dissolving it more than 200 mL of water to avoid esophageal injury.
3095 Non-Celiac Gluten Sensitivity (NCGS) Presenting as Laryngopharyngeal Reflux (LPR)
Authors: Son Joseph , Havranova Jana , Jaworek Aaron
Published: October 2019

INTRODUCTION:

Laryngopharyngeal reflux (LPR) is defined as retrograde passage of stomach contents through the esophagus into the larynx and pharynx. Celiac adhering disease is known to cause more severe reflux, often refractory to anti-secretory medications like proton pump inhibitors (PPI). In those cases, the patient will frequently experience symptom relief by adherence to a gluten free diet (GFD). However, little is known about non-celiac gluten sensitivity (NCGS), and the only commercially available test, Antigliadin (AGA) IgG, is positive in about 60% of patients. We present a case of LPR refractory to anti-secretory medication, low acid diet, and reflux surgery that resolved rapidly on a gluten free diet after diagnosing NCGS.

CASE DESCRIPTION/METHODS:

A 59 years old woman with PMH of gastric bypass surgery (roux-en-Y), GERD, hypothyroidism, MDD, and migraine presented with symptoms of hoarseness, mucous throat clearing, cough, sour taste, and nocturnal choking/laryngospasm events. Flexible fiberoptic laryngoscopy supported the diagnosis of LPR with classic findings of laryngeal edema, erythema, and inflammatory mucus. Treatment with omeprazole 40 mg BID, ranitidine 300 mg QHS, and aluminum hydroxide/magnesium carbonate failed to resolve her symptoms. Persistent severe acid reflux and strong symptom correlation were confirmed with dual sensor pH impedance while esophageal manometry confirmed hypotonic lower esophageal sphincter pressure. She underwent paraesophageal hernia repair and Dor fundoplication resulting in temporary resolution of symptoms that returned one month postoperatively. Although she was unaware of any gluten intolerance, she was tested for gluten sensitivity. Tissue Transglutaminase (TTG) IgA/IgG and Deamidated Gliadin Peptide (DGP) IgA/IgG were normal, but AGA IgG was elevated (111), suggestive of NCGS. She was instructed to follow a GFD, and within one week, all reflux symptoms had resolved, along with headaches, joint pain, and “foggy” mind.

DISCUSSION:

The patient had classic signs and symptoms of LPR, responsive to GFD, after NCGS was determined by elevated AGA IgG. NCGS remains the least understood form of gluten sensitivity, unlike its counterparts celiac disease and wheat allergy. By exploring the potential connections between LPR and gluten sensitivity, it becomes apparent that some of these patients have gluten sensitivity as the root cause of their reflux symptoms and laryngeal inflammation. More research is needed to better understand the influential diagnosis of NCGS.
3098 Small Plastic Objects Can Cause Foreign Body Impaction in Normal Adult Esophagus
Authors: Paul Navin
Published: October 2019

INTRODUCTION:

Foreign body impaction in the esophagus results from an inability of a swallowed object to pass through the esophagus to the stomach. In the United States, food, especially boneless meat, is the most commonly impacted foreign body. When impaction of a foreign body occurs in an adult esophagus, it usually occurs in the presence of underlying structural abnormalities (such as a web or stricture), functional abnormalities resulting from abnormal esophageal peristalsis, or when the swallowed object is too large to navigate the anatomic constrictions of the normal esophagus. This report describes two patients who had retained plastic foreign bodies in the esophagus in the presence of a normal esophageal anatomy.

CASE DESCRIPTION/METHODS:

Patient 1: A 39 year old man came to emergency room after accidentally swallowing a 2 cm plastic ring. He was able to swallow fluids and oral secretions, but felt a foreign body sensation in his upper chest. He denied any prior dysphagia. On endoscopy, a white plastic ring was seen in the mid-esophagus with no associated esophageal injury. Esophagus was normal with shiny mucosa. With insufflation and gentle prodding with the endoscope, the plastic ring easily passed into the stomach where it was captured using an endoscopic net and retrieved. The patient was discharged home after the procedure. Patient 2: A 53 year old woman presented to the emergency room with history of foreign body sensation and odynophagia localized to mid-chest after drinking an open cup of water. She was able to swallow water and oral secretions, but felt a sharp pain in the mid-chest every time she did so. Although she had seen a foreign body, she was convinced that she had foreign body stuck in her esophagus. Endoscopy showed a thin square piece of plastic measuring about 1 cm in size retained in a normal appearing esophagus with no obvious esophageal injury. It was retrieved using an endoscopic net. She was discharged home after the procedure.

DISCUSSION:

This report demonstrates that foreign bodies made of plastic can be retained in the adult esophagus in the absence of traditional risk factors. They can also present with atypical clinical features. The composition of plastic may make it more adherent to the esophageal mucosa thus preventing easy transit through the esophagus, even in the absence of restrictions in the esophagus. This report demonstrates the importance of endoscopic evaluation when a foreign body is suspected, even in the absence of a traditional presentation.
3103 A Case of Multiple Peptic Strictures Requiring Multistage Dilatation: A Challenging Esophagus
Authors: Nawaz Waqas , Fernandes Nikita , Hertan Hilary
Published: October 2019

INTRODUCTION:

Peptic strictures are benign esophageal strictures that result from chronic gastroesophageal reflux disease (GERD). Endoscopic dilatation is the treatment of choice. However, some strictures are complicated and difficult to manage. We present a case of an elderly male with two benign esophageal strictures, which were dilated in multiple sessions.

CASE DESCRIPTION/METHODS:

A 66-year-old male with a history of GERD, heavy smoking, excessive use of NSAIDS and alcohol was admitted for chronic dysphagia to solids for the last two years worsening over the last few months without significant weight loss. Physical exam and initial laboratory data were unremarkable. Upper endoscopy showed a benign appearing stricture at 18 cm from the incisors which could not be traversed with a regular or a pediatric scope. Barium esophagogram showed two areas of stricture in the proximal and the distal esophagus. The proximal stricture was dilated using a balloon dilator through the scope in multiple sessions. Finally, a10 mm dilatation was achieved where the pediatric scope traversed the stricture to examine the distal esophagus, which revealed esophageal diverticulosis. It showed a complex stricture at 36 cm from the incisors which was traversed. Biopsies showed intra-epithelial lymphocytes consistent with GERD without any eosinophil or atypical cells. Fluoroscopy guided dilation was done using Savary dilators up to a 14 mm diameter in three sessions with clinical improvement. Cessation of smoking, heavy alcohol and NSAIDS use was advised, and a proton pump inhibitor was started.

DISCUSSION:

Stricture formation occurs in 7–23% of patients with reflux esophagitis and GERD. Long term acid exposure results in chronic esophagitis with subsequent fibrosis of the muscularis propria leading to a fibrotic narrowing of the esophagus with formation of diverticula. Risk factors include male gender, advanced age, GERD, heavy alcohol use and NSAIDS. Work up includes upper endoscopy and barium esophagogram. Differentials include eosinophilic esophagitis and lye strictures. Biopsies are mandatory to rule out malignancy. Treatment involves acid suppression and dilation using wire guided polyvinyl bougie dilators under fluoroscopic or endoscopic guidance and balloon dilators which are passed through the endoscope. Perforation and bleeding may occur in 0.5 % cases. Our case was challenging as malignancy at the distal stricture could not be ruled out until the proximal stricture was dilated enough for the endoscope to traverse.
3104 Esophageal Hematoma: A Colossal Obstacle
Authors: Master Vidisha , Mehta Amit , Niec Rachel , Crawford Carl V. , Wan David
Published: October 2019

INTRODUCTION:

Esophageal hematomas are rare but well described phenomena that can present as retrosternal chest pain, hematemesis, and dysphagia. They are seen in association with anticoagulation therapy, mechanical trauma, and increased intraesophageal pressure as caused by excessive retching and vomiting. We describe a case of esophageal hematoma following catheter ablation for treatment of atrial fibrillation.

CASE DESCRIPTION/METHODS:

A 73 year old female with chronic obstructive pulmonary disease, nephrectomy, rheumatic heart disease status post mechanical mitral valve on warfarin, refractory atrial fibrillation was admitted for hematemesis after elective atrial fibrillation ablation. The patient underwent TEE during which an esophageal probe was required for repositioning of the esophagus. No blood was seen when the probe was removed, but at the end of the procedure the patient had hematemesis. INR at presentation was 3.7. The patient was emergently intubated and an EGD revealed a large clot occluding the mid-esophagus, denuded mucosa with oozing from multiple sites, and a large clot in the fundus (Figure 1). A chest CTA showed circumferential esophageal thickening and distention with non-enhancing blood products extending from above the thoracic inlet to the GE junction, with clot also outlined by oral contrast within the gastric lumen. No definite communication between the esophagus and atrial pulmonary veins was identified. A repeat endoscopy the next day again showed the large esophageal hematoma (Figure 2) and was aborted to avoid additional esophageal trauma. A week later, CTA chest showed persistent esophageal intramural hematoma with no evidence of aortoenteric fistula. Cardiothoracic surgery was consulted and placed a percutaneous gastrostomy tube. The patient was recovering well, but shortly upon extubation, the patient died of cardiorespiratory arrest.

DISCUSSION:

Esophageal hematomas typically develop in middle-aged women and present as a triad of retrosternal chest pain, dysphagia and hematemesis. The mechanism producing the hematoma may determine the site. For example, a hematoma from vomiting would be at the esophagogastric junction, whereas from a caustic substance might be at points of narrowing. It can be visualised on endoscopy or as a filling defect on barium esophagogram. Computed tomographic images reveal a mass confined to the esophageal lumen that does not enhance with injection of contrast medium. Conservative and supportive care remains the main therapeutic modality.
3105 Zenker's Diverticulum: Unusual Cause of Acute Oesophageal Impaction
Authors: Ali Hammad , Rahim Usman , Ehrinpreis Murray N.
Published: October 2019

INTRODUCTION:

Dysphagia amongst the elderly results from increasing dysfunction of the upper esophageal sphincter (UES), which is vulnerable to effects of aging. Prevalence of dysphagia in geriatric population, especially above 80 is higher than overall prevalence in the general population. Zenker's diverticulum (ZD) is the hallmark pathology for UES dysfunction. These false diverticula are herniation of mucosa and submucosa through the Killian's Triangle. Albeit progressive dysphagia is the most common presentation, symptoms can range from globus sensation to obstruction. ZD may rarely present as complete esophageal obstruction.

CASE DESCRIPTION/METHODS:

An 89 years old female with hypertension, osteoarthritis and polycythemia vera presented with complaint of “having a pill stuck in my throat.” Unable to tolerate her breakfast and spitting up sputum. Similar symptoms in the past for which she changed her diet to soft bread. Initially, it worked however dysphagia gradually worsened to the extent of having to butter her pills to ease swallowing. Denies GERD. Vital signs within normal limits, physical exam revealed enlarged multinodular goiter with retropharyngeal extension however negative Pemberton's sign. Boyce sign was positive on sipping some water. Euthyroid and no other abnormalities. Urgent upper endoscopy was recommended however patient refused but agreed the next day. Endoscopy was remarkable for pill lodged in upper esophagus, upper esophageal ring and impacted food in ZD compressing esophagus. The ring was split using the endoscope and pill pushed down which was then propelled by peristalsis to the stomach. Content of ZD was retrieved with Roth net. Remaining endoscopy exam was unremarkable. ENT evaluation was recommended for ZD and goiter however patient declined intervention.

DISCUSSION:

ZD often presents as solid food and pill dysphagia, rarely as acute esophageal obstruction as seen in this case. A number of factors in addition to external esophageal compression by the enlarging ZD likely contributed to her presentation, including pressure from enlarged thyroid. ZD compounds the pharyngeal weakness that leads to its development, trapping the patient in a vicious cycle of worsening dysphagia that eventually results in obstruction. Furthermore, an association between esophageal webs and ZD has been demonstrated. Combination of these factors resulted in the complete obstruction in our patient. Dysphagia in old age, always have ZD in mind.
3106 Cirrhosis and Barrett's? WATS-3D as a Screening Tool
Authors: Srinivasan Sachin , Agha Yasmine Hussein , Hyder Jeffrey , Wuthnow Chelsea , Kilgore William , Tofteland Nathan , Salyers William
Published: October 2019

INTRODUCTION:

Barrett's esophagus (BE) is a pre-malignant condition in patients with long-standing GERD. The gold standard for diagnosing BE is taking 4-quadrant esophageal biopsies during endoscopy followed by demonstration of intestinal metaplasia on histopathology. However, in patients with cirrhosis, taking biopsies is rendered difficult due to an increased risk of bleeding due to esophageal varices and coagulopathy. This case series reports three patients with cirrhosis that were successfully diagnosed with BE using WATS3D (Wide angle trans-epithelial sampling with computer assisted 3 dimensional tissue analysis).

CASE DESCRIPTION/METHODS:

Case 1: 66 year-old female with a history of cirrhosis secondary to autoimmune hepatitis, esophageal varices, GERD and previously diagnosed BE that had liver and kidney transplants 3 years prior to presentation. Case 2: 63 year-old male with a history of BE, Laennec's cirrhosis, esophageal varices and portal hypertensive gastropathy. Case 3: 62 year-old male with a history of cirrhosis due to untreated hepatitis C and alcohol abuse, known carrier for HFE gene, GERD and BE. Case 1 and 2 had WATS3D brushings and mucosal biopsies, while Case 3 had WATS3D brushings alone due to concerns of bleeding. The findings are described in Table 1. There was agreement between the WATS3D analysis and biopsy results in the 2 patients. The patient with WATS3D brushings alone had evidence of goblet cell metaplasia. There were no immediate or post-procedural complications (bleeding, infections) in any of the patients.

DISCUSSION:

Review of literature suggests that the prevalence of GERD and neoplastic progression in patients with cirrhosis is higher compared to patients without liver disease. However, weighing the benefits and risks of taking biopsies during EGD, many cases of BE go undetected when physicians refrain from taking biopsies and rely solely on endoscopic findings. WATS3D uses a minimally invasive brush biopsy that resects wide area tissue samples, allowing analysis of the full trans-epithelial thickness of the esophagus. It is less invasive than forceps biopsy, has a higher sampling yield, and would be safer in patients at high risk of bleeding complications in patients similar to those presented in this case report.
3107 A Case of Refractory Hyponatremia Treated by Anti-fungal Therapy
Authors: Mukherjee Samiran , Harne Prateek , Sharma Anuj , Singh Avneet , Manocha Divey
Published: October 2019

INTRODUCTION:

Hyponatremia is a commonly encountered condition in the ICU setting. Refractory hyponatremia due to esophageal/duodenal candidiasis is an unreported entity and is amenable to treatment with antifungal therapy.

CASE DESCRIPTION/METHODS:

We present a 74 year old lady who presented with shortness of breath and bilateral pleural effusions secondary to congestive heart failure with low sodium levels. Her co-morbid history included esophageal squamous cell carcinoma status-post esophagectomy with a duodenal conduit. The hyponatremia, initially thought to have been due to SIADH was non-responsive to fluid restriction and administration of salt tablets. Given her altered gut anatomy, it was later revealed to be due to malabsorption in either the duodenal conduit as a result of candidal duodenitis or due to an unconfirmed concomitant jejunal candidiasis. It had resolved after the candidiasis was treated with fluconazole therapy for a duration of 2 weeks.

DISCUSSION:

The occurrence of esophageal candidiasis in an immunocompetent individual is rare, more so is the occurence of pseudo-esophageal (duodenal) candidiasis. This case serves as an important teaching tool to understand the pathophysiology of hyponatremia in the setting of altered gut anatomy allowing us deeper insights into electrolyte balance.
3111 Achalasia in a Patient Newly Diagnosed With HIV
Authors: Elkhouly Mohamed A. , Attar Bashar M. , Mutneja Hemant , Demetria Melchor V.
Published: October 2019

INTRODUCTION:

Esophageal disease is common during HIV/AIDS infection and varies from esophagitis due to opportunistic infections as candida, cytomegalovirus and herpes simplex, to idiopathic ulcerations and non-specific motility disorders, but it has been suggested also that HIV infection itself can be the culprit of esophageal symptoms. We are presenting a case report of likely achalasia that was discovered in a patient newly diagnosed with HIV-1.

CASE DESCRIPTION/METHODS:

A 46-years-old male with no significant past medical history presented with 1 month history of recurrent attacks of nausea and non-bilious, non-projectile vomiting, 30-60 minutes following meals associated with anorexia, dysphagia and non-intentional weight loss of 10 lb. He did not have any fever, abdominal pain, diarrhea, constipation, hematemesis or melena. He was in a heterosexual relationship with no known contact to HIV infected patients. Examination was not evident of abdominal tenderness or any body swellings. Labs showed normocytic anemia with hemoglobin of 11.8 g/dl in addition to positive HIV-1 serology with viral load of 151,000 and CD4 count of 153. CT Chest was done showing sub-stantial dilation of the lower cervical, mid and distal esophagus with solid and gaseous contents. After 24 hours of “Nothing by mouth,” upper endoscopy was performed showing markedly dilated esophagus with esophageal mucosa covered with adherent food and secretions in addition to LA grade C esophagitis in the distal esophagus. Esophageal biopsy showed candida esophagitis with negative immunostains for CMV and HSV. He was started on HAART therapy and is awaiting manometry for confirmation of Achalasia diagnosis.

DISCUSSION:

It is accepted that HIV is aneuropathic virus and it has been related to loss of autonomic nerves in different parts of the body. Motor abnormalities have been identified in the esophagus, stomach and small intestine. The case report highlight that HIV maybe considered as possible infectious cause of achalasia.
3114 A Common Gastrointestinal Manifestation of an Uncommon Disease
Authors: Elkhattib Ismail , Aujla Amreet K. , Villavicencio Jaimy , Siddique Osama , Vaziri Haleh
Published: October 2019

INTRODUCTION:

Inclusion body myositis (IBM) is a chronic progressive myopathy characterized by dysphagia in 10% to 73% of patients with one-year mortality of 31% in patients with symptoms of dysphagia. We present a case of a patient with IBM esophagitis causing severe weight loss and complete loss of ability to swallow with a discussion of potential management modalities.

CASE DESCRIPTION/METHODS:

The patient was a 77-year-old male with a past medical history of inclusion body myositis diagnosed at age of 57 and muscular dystrophy who presented with progressive dysphagia for several years and a significant weight loss of 40 pounds over last 8 months. He initially was able to tolerate small bites, however, he was not able to tolerate solids and his diet was modified to a mechanical soft diet. Prior to the hospital admission, the patient had an outpatient modified barium study (MBS) which revealed penetration and aspiration with thin and nectar thick liquids. An endoscopy was attempted for percutaneous gastrostomy tube placement but was unsuccessful due to the inability to pass through the upper esophageal sphincter. He subsequently underwent a fluoroscopy-guided percutaneous gastrostomy tube placement by an interventional radiologist.

DISCUSSION:

IBM is a chronic progressive inflammatory myopathy. Associated dysphagia can result in nutritional deficits, weight loss, aspiration pneumonia and decreased quality of life. The underlying mechanism for dysphagia is related to inadequate pharyngeal contraction, poor relaxation of the cricopharyngeal muscle, and reduced hyolaryngeal elevation. The management of dysphagia in IBM is challenging due to its steroid resistance nature. Multiple treatment modalities are used to treat dysphagia secondary to IBM, including conservative measures, intravenous immunoglobulin therapy, and balloon. Surgical intervention with cricopharyngeal myotomy has been suggested when conservative therapies fail or when severe weight loss and malnutrition are apparent. The later appears to be effective especially when hypertonicity of the cricopharyngeal muscle and impaired relaxation are present. A retrospective study of 26 patients with IBM has shown higher mortality in patients who required PEG placement compared to the ones who underwent cricopharyngeal myotomy. Per-oral endoscopic myotomy (POEM) showed success for spastic esophageal disorders such as diffuse esophageal spasm. At the meantime, no studies have implied the procedure for IBM esophagitis giving a great room for future studies.
3116 Dilated Rectum in Psychotic Patient—Stercoral Colitis Causing Complications
Authors: Patel Pranav D. , Chaudhari Jignaben , Mehmood Asif , Radadiya Dhruvil K. , Bergenstock Marika
Published: October 2019

INTRODUCTION:

Constipation is common finding in hospitalized patient from nursing home, psychiatry unit or hospice facility. Assessment of abdominal symptoms in patient with psychiatric illness is challenging. Their medication compliance and lifestyle modification are not optimal due to limited insight. We present such case with constipation ended up with complicated hospital stay.

CASE DESCRIPTION/METHODS:

71-year-old male who is sent from inpatient psychiatry hospital for abdominal distention and an episode of bilious vomiting. His caregiver has notified patient has inadequate oral intake from last 2 weeks. His past medical history includes schizophrenia, hypothyroidism, gastroesophageal reflux disease, status post cholecystectomy, benign prostate hyperplasia and chronic constipation. Prior to admission he is on laxatives polyethylene glycol, senna and docusate but he is not taking regularly. Abdominal CT scan with IV without oral contrast revealed extensive stool burden with severely distended rectum 9.4 cm diameter (Figure 1), stercoral colitis, small intestinal focalization, esophageal thickening suspected esophagitis. Patient is required nasogastric tube placement, manual fecal disimpection, frequent enemas, multiple laxatives to improve constipation. His hospital stay is prolonged and further complicated with acute blood loss anemia due to upper gastrointestinal bleeding. EGD revealed reflux esophagitis, erosive gastropathy likely caused by vomiting, urinary retention secondary to constipation and concern of aspiration. Psychiatry evaluation is sought to adjust antipsychotic medication to help lessen constipation as side effect.

DISCUSSION:

There is substantial risk of gastrointestinal hypomotility in patient receiving first generation or atypical antipsychotics. Most of the antipsychotic medications have anticholinergic side effect leading to constipation. Other psychosocial factors that can contribute are limited water consumption, lack of physical activity, inexpressive to thirst or abdominal symptoms, labile mood hampering medication compliance. Such patients are likely to have higher rate of hospitalization and complications like reflux esophagitis, urinary retention, aspiration, risk of perforation or gastrointestinal bleeding like in this patient. Vigilant bowel movement record and early initiation of constipation treatment at living facility is important in such patients.
3120 Polyethylene Glycol-Based Bowel Preparation Induced Episodic Sinus Arrest: The Bezold-Jarisch Reflex
Authors: Rathbun John , Raizada Veena , Severson Elizabeth , Huang Andy , Ling Christina , Rustagi Tarun , Sheldon Mark
Published: October 2019

INTRODUCTION:

The Bezold–Jarisch reflex (BJR) is a cardiac reflex that increases parasympathetic tone and inhibits sympathetic activity, resulting in a clinical triad of bradycardia, hypotension, and peripheral vasodilation. This reflex can be activated by chemical stimuli, such as anesthesia, or by reduced cardiac venous return. Inappropriate reflex bradycardia or asystole can occur.

CASE DESCRIPTION/METHODS:

A 51-year-old female with no past medical history underwent bowel preparation with a polyethylene glycol-based solution for a routine screening colonoscopy. Before anesthesia was administered, the patient became unresponsive and clonic with a 3-4 second sinus pause. On physical exam, the patient was dehydrated. Electrolyte findings were within normal limits, aside from sodium level of 123 mmol/L. The patient eventually recorded a sinus pause of 30 seconds and a transvenous pacemaker was placed for episodic sinus arrest. The Bezold–Jarisch reflex is a diagnosis of exclusion. The patient had a negative D-dimer, three non-detectable troponin levels and a CT pulmonary angiogram negative for pulmonary embolism. Two electrocardiograms showed normal sinus rhythm, with repeat showing sinus bradycardia; intervals were within normal limits. A transthoracic echocardiogram showed an ejection fraction of 65% with no valvular disease or structural abnormalities. After the patient was fluid resuscitated and electrolytes were optimized, no further episodes were recorded. The patient was fitted with an event monitor and discharged home with close follow up. She remained asymptomatic at outpatient appointment.

DISCUSSION:

The patient's bowel preparation for her colonoscopy resulted in hypovolemic hyponatremia, upregulating her renin-angiotensin-aldosterone system, whichvagally mediated her episodic sinus arrest via the Bezold–Jarisch Reflex. Given the increasing rate of colonoscopies, this case report highlights the importance of electrolyte-balanced hydration in preventing a potential BJR.
3124 Endoscopy in Patient With Situs Inversus Totalis
Authors: Yun Lisa S. , Clark August , Anderson Karl
Published: October 2019

INTRODUCTION:

Situs inversus totalis (SIT) is the complete transposition of the abdominal and thoracic organs. Due to the inherent anatomic differences, patients with situs inversus may pose a unique challenge when undergoing endoscopic procedures because physicians are trained to maneuver the endoscope in a certain manner.

CASE DESCRIPTION/METHODS:

A 51 year old male presents with a 3 year history of intermittent rectal bleeding. He denies abdominal pain, constipation, and diarrhea.

On presentation, physical exam was normal. Although the patient was aware of his diagnosis of SIT at the time of endoscopy, he did not think it was necessary to inform physicians about his condition. In addition, multiple electrocardiograms had been read previously without complications. Laboratory evaluations were normal except for slightly elevated ALT and AST. EGD was performed and showed salmon-colored mucosa in the distal esophagus. Biopsies of the esophagus showed squamous epithelium with acute inflammation and reflux-associated changes, and no evidence of intestinal metaplasia. The stomach was diffusely erythematous and biopsies revealed chronic active gastritis with H. pylori-like organisms. Colonoscopy was normal with the exception of internal hemorrhoids. EGD and colonoscopy were both successfully performed in the standard manner. SIT was discovered during a liver ultrasound performed to further investigate the etiology of his elevated liver function tests.

DISCUSSION:

Situs inversus totalis may cause additional challenges for endoscopists. One study found that SIT prolonged cecal intubation times. Certain modifications to standard endoscopic technique have been proposed including turning the endoscope 180 degrees clockwise first in the stomach then again in the duodenum, as well as placing the patient in the right lateral decubitus position so that the maneuvers are performed inversely.

In our case, the endoscopist was able to successfully navigate the endoscopic procedures without special maneuvers or changes in position and was unaware of the diagnosis of SIT until after the procedure. In conclusion, endoscopies and colonoscopies are feasible in patients with SIT. Various modifications to the endoscopic technique have been suggested, but may not always be required, to safely perform these procedures on patients with SIT.