bluuebunny/crossref_metadata_2025 huggingface dataset:
1858 Corneal Injury After Routine Gastrointestinal (GI) Endoscopy With Moderate Sedation
Authors: Dixon Robert , Adler Douglas G. , Timm Stephanie , Fang John C.
Published: October 2019

INTRODUCTION:

Corneal abrasion is the most common ocular adverse event from deep sedation and general anesthesia. Its occurrence during moderate sedation for gastrointestinal (GI) endoscopy has not been previously reported. We report 5 cases of corneal abrasion following standard GI endoscopy under moderate sedation.

CASE DESCRIPTION/METHODS:

Retrospective chart review of ocular adverse events during endoscopy collected prospectively from our endoscopy quality system.

5 cases were identified from May 2013 to January 2019. All patients (4 men, 1 woman; age 45-76) underwent routine endoscopy (2 upper endoscopies, 2 colonoscopies, 1 upper endoscopy and colonoscopy) and noted ocular discomfort during recovery from the procedure. All procedures were performed under moderate sedation with 4 patients receiving non-anesthesiologist administered propofol sedation in our hospital endoscopy lab and the 5th patient receiving monitored anesthesia care (MAC) propofol sedation in the medical ICU. Procedure times ranged from 15 minutes to 2 hours 18 minutes. Oxygenation methods included two by nasal cannula (4L/min and 6L/min), two by non-rebreather mask (12 L/min), and one by Bilevel positive airway pressure mask (BiPAP). Ophthalmological examination confirmed the presence of a corneal abrasion in all cases. No patients had prior ocular disease or injury.

DISCUSSION:

Moderate sedation for GI endoscopy is very safe, but there exists a risk for corneal injury which has not been previously reported. Endoscopists and unit staff should be made aware of this complication, which is likely underrecognized. Training to ensure patient’s eyelids are fully closed during procedure, supplemental oxygen delivery systems are properly fitted and that there is no direct contact between the dependent eye and underlying head support can prevent this complication.
1864 Gastric Outlet Obstruction as a Complication of Replaced Gastrostomy Tube
Authors: Walradt Trent , Martin Tracey , Kieber-Emmons AnnMarie , Wan David
Published: October 2019

INTRODUCTION:

Percutaneous endoscopic gastrostomy (PEG) is a common procedure for the provision of long term enteral nutrition (1). Indications for PEG tube replacement include tube malfunction, dislodgement, or scheduled exchange (2). Complications of replacement include bleeding, infection, and tube misplacement (3). Gastric outlet obstruction (GOO) is a rare complication seen when the tube is inserted distal to the pylorus or the balloon is overfilled (4).

CASE DESCRIPTION/METHODS:

An 86-year-old woman with a history of previous stroke necessitating prolonged enteral feeding through PEG presented to the hospital due to a clogged PEG tube. The tube was replaced at bedside via the percutaneous route and gastric fluid was aspirated. The tube was noted to be 2 cm deeper than prior to the procedure. A water-soluble contrast study through the PEG tube was obtained to confirm proper position (Figure 1) which showed contrast within the small bowel. The radiologist concluded the gastrostomy tube was in satisfactory position and tube feedings were resumed. Overnight, the patient experienced several episodes dark emesis. An endoscopy the next morning revealed the gastrostomy tube balloon was inflated in the duodenal bulb causing a GOO (Figure 2). The tube was repositioned in the stomach (Figure 3) and the patient was discharged 4 days later.

DISCUSSION:

This case illustrates the importance of establishing a standardized approach to the confirmation and documentation of PEG tube replacement. The marker on the replacement tube should be close to that of the previous tube. Notably, resistance to traction at a greater depth than expected may represent post-pyloric placement of the balloon. Finally, when imaging is obtained, fluoroscopy should be performed at an oblique angle and contrast should be observed in the stomach to confirm correct placement.
1867 A Case of Mistaken Identities: Impact of Kayexalate on the Colon
Authors: Nagirimadugu Ankita , Hershman Melissa , Ascunce Gil
Published: October 2019

INTRODUCTION:

End stage renal disease (ESRD) affects nearly 750,000 Americans each year. Kayexalate (sodium polystyrene sulfonate) is commonly used to manage hyperkalemia in ESRD. Kayexalate is a nonspecific cation exchange resin that acts in the large intestine to allow for the exchange of sodium for any cation (potassium, calcium or magnesium). Kayexalate has an inherent lattice structure. Addition of calcium ions can lead to crystal formation that appears basophilic, rhomboid/triangular with a fish-scale appearance on Hematoxylin and Eosin (H&E) stain. Studies show that the combination of kayexalate and sorbitol, an osmotic laxative, may lead to osmotic shifts and ischemic damage. However, the impact of kayexalate alone in gastrointestinal tract is less established. We present a case of kayexlate crystal deposition appearing as a pseudo-polyp in the appendiceal orifice.

CASE DESCRIPTION/METHODS:

A 51-year-old woman with a past medical history significant for systemic lupus erythematosus, radical nephrectomy for renal mass complicated by dialysis dependent ESRD, mitral and aortic valve replacement on Coumadin, presented to the hospital for hyperkalemia requiring emergent dialysis. The patient developed melena in the setting of supratherapeutic INR. Colonoscopy revealed a non-obstructing 10mm yellow mass protruding from, and tethered to, the appendiceal orifice. The pseudo-polyp appeared to be on a stalk. Resection was performed using a biopsy forceps at the base. Pathology revealed foreign crystalline material that was suggestive of kayexalate deposition. The source of gastrointestinal bleeding was later identified as a jejunal arteriovenous malformation.

DISCUSSION:

Reports of kayexalate effects on the gastrointestinal tract are somewhat limited, but include findings of acute inflammatory tissue injury in as early as 24 hours, potentially with colonic ulceration. Kayexalate can also cause mechanical obstruction secondary to the development of crystalline structures in the colon. Prolonged uses of this medication can likewise lead to reversible crystal deposition within the esophagus, stomach and duodenum. This case highlights the potential for crystal resin deposition to appear as a pseudopolyp. Gastroenterologists should carefully review medication history when approaching a patient with a mechanical obstruction or colon ulceration in the setting of ESRD.
1869 A Case of Black Esophagus
Authors: Haddad Ibrahim , El Kurdi Bara , Babar Sumbal , El Iskandarani Mahmoud , Al Momani Laith , Alomari Mohammad , Young Mark
Published: October 2019

INTRODUCTION:

Acute esophageal necrosis (AEN), commonly known as “black esophagus”, is a rare clinical diagnosis that was described for the first time in 1990 by Goldenberg. Since its first description, less than 100 documented cases were found in the literature. We present a 47 years old female who had this rare lethal condition.

CASE DESCRIPTION/METHODS:

A 47-years-old female with a past medical history significant for alcohol use disorder, gastroesophageal reflux disease, and severe malnutrition, who presented with hematemesis that started after multiple episodes of induced vomiting aiming to detoxify her body from recent heavy drinking according to the patient. At presentation, the patient was in hypovolemic shock and was given normal saline boluses, intravenous omeprazole and admitted to the intensive care unit. Complete blood count showed a drop in her hemoglobin level form her baseline 9 mg/dl to 4.6 mg/dl and was transfused with two units of packed red blood cells. After clinical stabilization, urgent esophagiogastrodudenoscopy (EGD) was done and showed severe esophageal ulcerations, erosions, and necrosis, findings suggestive of acute esophageal necrosis (Figure 1) and active diffuse gastric bleeding. Patient’s hemoglobin dropped again to 4 mg/dl, upon which she received a massive transfusion, was intubated for airway protection and started on vasopressors for hypovolemic shock unresponsive to intravenous fluid. After 4 days patient’s blood pressure normalized, her hemoglobin level stabilized and was extubated successfully. The patient was discharged home on a proton pump inhibitor and sucralfate. EGD was repeated after 2 weeks from discharge (Figure 2) and showed significant improvement of the mucosal abnormalities compared to her initial EGD.

DISCUSSION:

AEN is a rare but potentially lethal condition that is believed to be multifactorial in origin with a combination of ischemic insult, corrosive injury from gastric contents and decreased the function of the mucosal barrier, all of them play a major role in its pathogenesis. The mortality rate ranges from 30% to 50% and it’s largely influenced by the severity of the coexisting medical problems. Complications might be acute such as bleeding, mediastinitis, and perforation or chronic such as strictures formation and stenosis. The management is focused mainly on treating the underlying conditions, improving blood supply and acid suppression.
1875 Acute Pancreatitis Due to Clipping of the Ampulla With Over-The-Scope Clip as a Complication of Bleeding Duodenal Ulcer Treatment
Authors: Sehmbey Gurbir , Srinivasan Indu , Chuang Keng-Yu
Published: October 2019

INTRODUCTION:

Over-the-scope clips (OTSC; Ovesco, Tübingen, Germany) are extensively used for management of gastrointestinal (GI) bleeding, stent anchoring, fistulas, and bowel perforations. Its mechanism of action includes mechanical compression and tissue approximation. Removal of OTSC is indicated when complications occur, which include ulceration, luminal obstruction or clip misplacement. ReMOVE system (Ovesco, Tübingen, Germany) is a safe and effective tool designed to remove the clip.

CASE DESCRIPTION/METHODS:

A 56-year-old male presented to our hospital with abdominal pain and rectal bleeding for 4 days. On examination, the patient had epigastric tenderness and rectal exam revealed melanotic stool with bright red streaking. Labs revealed Hgb of 10.4 g/dL. CT abdomen/pelvis revealed active bleeding in the 2nd and 3rd portion of the duodenum. The patient was started on pantoprazole and red blood cell infusion. EGD revealed a peptic ulcer with an exposed vessel in the 2nd portion of duodenum proximal to the ampulla (Figure 1). Hemostasis was achieved using epinephrine injection and placement of an Ovesco OTSC. Patients hemoglobin stabilized however he continued to experience excruciating abdominal pain. Serum lipase was checked and was elevated to 17,925 U/L. A repeat EGD showed OTSC deployed over the ampulla (Figure 2) and attempts to break the clip using a needle knife and APC were unsuccessful. Two days later, using the bipolar direct current (DC) cutter (remOVE system, Ovesco, Tübingen, Germany) (Figure 3) the clip was removed following which bile was seen to be draining freely. Repeat EGD 1 month later showed normal duodenum with healed ampulla and ulcer.

DISCUSSION:

Ovesco OTSC is an innovative clipping system intended for endoscopic treatment of GI bleeding and closure of acute or chronic wall lesions. The OTSC for flexible endoscopy is an elastic device that works by compression and approximation of tissue. The clip is composed of Nitinol, a biocompatible material that can remain in the body as a long-term implant. RemOVE system can be used for endoscopic OTSC clips removal from the GI tract. It includes DC Cutter which is a bipolar instrument that allows fragmentation by localized melting and cutting of OTSC when used with DC Impulse. The DC Cutter’s tip consists of three electrodes that are brought in contact with the thinnest parts of the nitinol clip which is the frame/hinge. The OTSC must be cut at two spots on opposite side of the row of teeth and the clip fragments can be extracted.
1878 Migration of Over-the-Scope Clip (OTSC) Resulting in Intestinal Obstruction
Authors: Khalid Sameen , Satiya Jinendra , Abbass Aamer , Parasher Gulshan , Castresana Daniel
Published: October 2019

INTRODUCTION:

Iatrogenic perforations are a known and feared complication of diagnostic and therapeutic colonoscopy. Over-the-scope clips (OTSCs) have recently been utilized for management of these perforations. We present the case of a 40-year-old male patient treated with over-the-scope (Ovesco®) clip for an iatrogenic post-polypectomy perforation with subsequent intestinal obstruction occurring as a result of migration of the clip.

CASE DESCRIPTION/METHODS:

A 40-year-old male with familial adenomatous polyposis and total proctocolectomy, ileoanal anastomosis and a J pouch had an ileoscopy performed for polyp surveillance. A 3 cm flat polyp was removed with Eleview® injection lift technique. A hole like defect was noted in the postpolypectomy site that developed into an obvious small 2-3 mm perforation. To repair the defect, a one 14/6 mm type gc over-the-scope clip (Ovesco®) and a 12/6 mm type gc over-the-scope clip (Ovesco®) was successfully placed. Four months later the patient presented to the emergency department with severe anal pain. He felt a hard metallic object in the anal canal. He denied any fevers, chills, nausea, vomiting, or abdominal pain. Rectal tenderness was found on digital rectal examination. A CT abdomen and pelvis showed an object of metallic density at the anal verge with nonobstructive bowel gas pattern. Colonoscopy revealed two over-the-scope clips approximately 2 cm from the anal verge embedded in the mucosa (Figure 1) which were removed. The patient did well post procedure and was discharged home the next day.

DISCUSSION:

The Ovesco® clip (Ovesco, Tübingen, Germany) is a novel endoscopic method to achieve mechanical compression of gastrointestinal tissue with current indications including closure of fistulas, iatrogenic perforations, hemostasis and non-variceal gastrointestinal bleeding. Iatrogenic perforations during colonoscopy have an incidence ranging from 0.1% to 0.3% of cases. These complications carry a high mortality rate and in the past warranted surgical intervention. However, with the advances in therapeutic endoscopy many perforations can be managed effectively with endoclips, OTSCs and/or endosuturing. These new techniques do come with device-specific risks. Fischer et al. reported the first case of OTSC-induced bowel obstruction. Here we present another case of bowel obstruction as a result of OTSC placement for a perforation, treated with surgical intervention. All gastroenterologists should be aware of clinical scenarios in which the Ovesco clip can be used.
1881 Incidental Finding of an Inverted Appendix in an Asymptomatic Patient With No Surgical History
Authors: Evans Nicole S. , Quezada Michael , Ippoliti Andrew , Shaker Anisa
Published: October 2019

INTRODUCTION:

An inverted appendix is a rare colonoscopic finding that typically occurs in patients who have undergone an inversion-ligation appendectomy or developed an appendiceal intussusception. There are very few cases of patients with an inverted appendix of unknown etiology reported in the literature. We report a case of an inverted appendix that was incidentally found during colonoscopy in an asymptomatic patient without intussusception or previous appendectomy.

CASE DESCRIPTION/METHODS:

A 66-year-old male with a history of essential hypertension, stage IV chronic kidney disease and atrial fibrillation was referred for a colonoscopy for colorectal cancer screening. He denied any abdominal pain, nausea, vomiting, melena, hematochezia, or other active complaints on initial examination. He has no known surgical history and denies family history of colorectal cancer. Colonoscopy was performed and showed a bulbous-appearing mass protruding into the lumen of the cecum. Examination of the lesion under narrow band imaging revealed normal mucosa. The rest of the exam was unremarkable. Several endoscopists reviewed the imaging of the bulbous-appearing caecal mass, and given the location and appearance of this abnormality, a clinical diagnosis of an inverted appendix was made. Further radiological confirmation with contrast imaging was deferred given the patient’s renal failure. The patient was advised to follow up if any new symptoms developed.

DISCUSSION:

Appendiceal inversion is a unique colonoscopic finding which can mimic other more commonly observed polypoid lesions. Over the past years, only a few cases have been reported in the literature, with even fewer cases limited to patients without history of prior appendectomy, known cystic fibrosis or endometriosis, or evidence of intussusception. As such, the diagnostic features and treatment measures may vary among cases. This case should serve as a reminder to endoscopists to remain aware of such unique anatomic variants and to accurately differentiate these from other more concerning lesions.
1891 Esophageal Intramural Pseudodiverticulosis and Concomitant Esophageal Candidiasis
Authors: Morissette Patricia D. , Kirkpatrick Paul , Tetangco Eula Geralyn , Schubert Moonkyung
Published: October 2019

INTRODUCTION:

This case pertains to a 65 yo AA M who presented with chronic dysphagia. Multiple EGDs were performed and Esophageal Intramural Pseudodiverticulosis (EIP) was noted along with Esophagitis, strictures and esophageal candidiasis. Esophageal Pitting, or EIP, is described as longitudinal rows of multiple small flask-shaped outpouchings protruding from the esophagus (1,4). Although EIP is not particularly prevalent, esophageal candidiasis is found in 50% of these cases (1). Consisely, clinicians should be aware of EIP and it’s strong association with dysphagia, strictures, and esophageal candidiasis, as such, biopsies should be taken on EGD.

CASE DESCRIPTION/METHODS:

65 yo AAM, with significant PMHx of IDDM and GERD, presented with chronic dysphagia (pills and solid food). On presentation, patient denied any other GI or chest complaints. Patient underwent EGD: Numerous pits were seen in the mid esophagus [Figure 1]. Multiple biopsies were taken and pathology demonstrated fragments of esophageal mucosa with acute esophagitis and yeast forms were identified. Patient also had distal esophageal stricture, which was balloon dilated. He was then lost to follow up. Several years later he returned with dysphagia. On Repeat EGD, diffuse esophageal pitting was seen from 25 cm to the EGJ [Figure 2]. Pathology demonstrated acute esophagitis with focal fungal elements [Figure 3]. No malignancy was seen. Patient was started on appropriate antifungal and daily PPI. Repeat EGD was scheduled for 3 months.

DISCUSSION:

EIP, as noted in our patient, although a rare finding, can be seen in patient’s with Dysphagia (1). 80% of symptomatic patients present with intermittent or progressive dysphagia (1,3). Etiology of EIP to date is unclear. Some association has been seen with inflammatory disease of the esophagus (chronic esophagitis or infectious) (1–4). Management focuses on symptomatic relief along with treating the underlying disease (1,3).
1893 Non-Surgical Endoscopic Management of a Sealed Nail Perforation in the Gastric Antrum
Authors: Tien Andy , Dong Elizabeth , Fahmy Marianne
Published: October 2019

INTRODUCTION:

Foreign body ingestions are most commonly seen in children, elderly adults, and patients with psychiatric conditions. Perforation is a feared complication, often requiring surgical intervention. We present a case of endoscopic removal of a sealed nail perforation with an over-the-scope clip closure in a patient who was a high-risk surgical candidate.

CASE DESCRIPTION/METHODS:

A 48-year-old homeless male with a history of multiple abdominal surgeries due to gunshots and stab wounds complicated by abdominal hernias presented with 1 week of abdominal pain after drinking an open bottle of soda. Vital signs were stable on presentation. Labs were unremarkable. Computed tomography (CT) revealed a needle-like foreign body in the antrum of the stomach that appeared to project beyond the lumen without signs of pneumoperitoneum free perforation or fluid (Figure 1). An upper endoscopy was performed to further characterize the foreign body. Upon entering the stomach, a 2mm round metallic circular object (Figure 2) was visualized along the lesser curvature of the antrum, suggestive of a nail embedded into the gastric antrum. General surgery was consulted given concern for perforation, however, the patient was deemed a high-risk surgical candidate due to hostile abdominal scarring. The decision was made for endoscopic repair of the nail perforation. On repeat endoscopy, the nail was again visualized in the lesser curve of the antrum; rat-tooth forceps were used to remove a 2.8cm rusty nail (Figure 3) which was safely pulled through an overtube. The scope was reinserted with an over-the-scope clip attached, which was then successfully deployed at the site of perforation. Patient tolerated the procedure well with no signs of peritonitis and follow-up CT four days post-procedure showed the clip in place.

DISCUSSION:

Complications such as perforations and abscesses occur in less than 1% of foreign body ingestions. The most common sites of perforation are the ileocecal valve and other points of intestinal angulations. There are limited cases in the literature of endoscopic intervention in a sealed nail perforation in the stomach in an adult. We found that an over-the-scope clip was effective in sealing a small perforation without evidence of peritonitis on follow-up examinations. Coordination with the surgical service is important in endoscopic repair of perforations. Overall, endoscopic removal of a sealed nail perforation is a viable option for high-risk patients.
1896 Jejunal Migration of Double Pigtail Stent Successfully Removed by Enteroscopy
Authors: Yang Tsujung , Ghimire Subash , Avetisova Mariam , Shah Harshil , Lincoln Matthew J. , Kirshan Ravi Shri Jai
Published: October 2019

INTRODUCTION:

Walled-off pancreatic necrosis, pseudocyst, and intra-abdominal abscess are common complications after pancreatectomy. Based on the location, the endoscopic drainage can be performed with placement of double pigtail stents. However, the stent itself can cause distal migration months to years later, and it can lead to viscera perforation if not removed in a timely fashion.

CASE DESCRIPTION/METHODS:

We present a case of a 63-year-old woman with history of pancreatic adenocarcinoma status post distal pancreatectomy, splenectomy and partial gastrectomy. Post-surgery, she developed peri-pancreatic fluids collection posterior to the stomach. She underwent cyst duodenostomy, cyst gastrostomy, serial necrosectomies, and sequential placement of AXIOS LAMS (lumen apposing metal stents) and double pigtail plastic stent. LAMS were removed serially after the drainage but double pigtail stent was left behind. A year and half later, she presented to our hospital with left upper abdominal pain for four days. The pain was sharp, stabbing, radiated to left flank, and worsened with deep inspiration and body movements. The review of systems was not significant. She was afebrile and vitals were stable. Physical exam was only significant for moderate tenderness in left upper quadrant and left flank region. Labs showed leukocytosis, thrombocytosis, but normal kidney and liver functions. CT abdomen and pelvis with contrast showed distally migrated double pigtail stent in the mid-jejunum. Enteroscopy using the colonoscope was introduced into the mid-jejunum. A foreign body consistent with the double pigtail stent was found. It was removed with rat-toothed forceps. No perforation was evident post procedure. The abdominal pain resolved completely several hours after the procedure.

DISCUSSION:

Distal stent migration is a possible remote complication if the double pigtail stent remained after complete drainage of intra-abdominal abscesses or pseudocysts. Endoscopic removal is a safe and effective procedure provided that there is no bowel perforation.
1900 Crushing the Star: Esophageal Foreign Body Extraction Using Dormia Basket
Authors: Kilakkathi Sindhu , Shah Rushikesh , Mulki Ramzi , Qayed Emad
Published: October 2019

INTRODUCTION:

Sharp objects impacted in the esophagus require prompt endoscopic removal. Removal of sharp foreign bodies can be technically challenging and care should be taken to avoid inducing esophageal trauma during retrieval.

CASE DESCRIPTION/METHODS:

A 69-year-old female presented with sudden onset dysphagia and sharp chest pain for 1 day. While eating cake one day prior to arrival, she reported sudden, sharp, central chest pain followed by a sensation of food being stuck in her esophagus. Her physical examination was unremarkable with no abdominal tenderness. Her laboratory tests revealed normal complete blood count and chemistry. Chest x-ray revealed no acute abnormality. Upper endoscopy showed a sharp star-shaped foreign body (FB) approximately 2 cm in diameter (Figure 1). The FB was lodged in the distal esophagus, causing mucosal trauma. Due to the large size of the FB, insertion of an overtube was not considered to facilitate removal. An attempt was first made to extract the FB with rat-tooth forceps, but it could not be retrieved through the upper esophageal sphincter. Mucosal trauma was seen in the mid and proximal esophagus following this attempt. The FB was then advanced to the gastric antrum using a Roth net. Attempts to break the FB using argon plasma coagulation (APC) and a snare were unsuccessful due to the rigid nature of the FB. Subsequently, a 2T dual channel therapeutic gastroscope was inserted, and a Dormia stone retrieval basket was used to grasp the foreign body. Using the crushing power of the basket, the FB was successfully crushed and pulled inside the large therapeutic channel of the scope. The scope was withdrawn without additional mucosal trauma. The FB consisted of a star-shaped cake decoration with sharp edges (Figure 2). Following the procedure, the patient reported immediate improvement in her chest pain.

DISCUSSION:

This is a unique case wherein after the failure of conventional foreign body extraction devices, a Dormia stone retrieval basket was used to crush the object within the stomach allowing for safe retrieval. Gastroenterologists should consider this approach when retrieving irregularly-shaped, sharp, but pliable FBs. For the general public, care should be taken when eating food with non-edible decorations and toppers to avoid inadvertently swallowing or aspirating these objects.
1901 PEG Tube Induced Choledo-Duodenal Fistula: When to Expect the Unexpected
Authors: Jakkidi Manisha , Edirisuriya Cynthia , Elfant Adam , Cooper Robert , Chaaya Adib
Published: October 2019

INTRODUCTION:

PEG tube has become the modality of choice for providing access for long term enteral nutrition. Despite a good safety record, complications due to PEG dislodgment do occur. We present a case of PEG tube causing Choledo-duodenal fistula, presenting with Ascending Cholangitis. To the best of our knowledge, this unusual complication of PEG tube hasn't been described before.

CASE DESCRIPTION/METHODS:

38 y.o.male with anoxic brain injury, PEG tube placed 6 months ago, presented for evaluation of Jaundice. Vitals were BP 145/108 | Pulse 135 | Temp 101.5 °F. On exam, patient had jaundice, abdomen was soft, Non tender, PEG tube was in the LUQ and Murphy’s sign was negative. Labs showed WBC 12 10X3 U/L, AST 46 U/L, ALT 131 U/L, TB 2.2 mg/dL, DB 1.1 mg/dL. CT abdomen and Pelvis revealed intrahepatic, extrahepatic and CBD dilatation to 1.2 cm, normal Pancreas. PEG tube with fluid-filled balloon was at the level of the pylorus or proximal duodenum. Small and large bowel were nondilated. The diagnosis of ascending cholangitis was made and ERCP was performed. ERCP showed the PEG tube balloon in the duodenum. It was repositioned into the stomach and the scope was advanced to the 2nd portion of the duodenum. There was a large white base ulcer at the duodenal sweep extending into the 2nd portion of the duodenum. Occlusion cholangiogram showed extravasation of the contrast from the distal CBD into the duodenal ulcer. There was a fistulous tract between the CBD and the ulcer. Sphincterotomy was made and a biliary stent was placed to heal the fistula. Biospy of the ulcer showed small intestinal mucosa with ulceration, fibrinoid exudates and no malignancy. Repeat ERCP 8 weeks later for stent removal, showed a chronic entero-biliary fistula.

DISCUSSION:

Our case is unique in that, this is the first CD fistula described in the literature as a complication of PEG tube presenting with ascending cholangitis. We hypothesize that the inflated balloon migrated into the duodenum due to gastric peristalsis and got incarcerated into the duodenum. 90% cases of CD fistula are due to impacted stone in the distal CBD. Other causes are Ampullary carcinoma or Cholangiocarcinoma. Based on our literature review, this is the only reported case of CD Fistula resulting from dislodged PEG tube causing direct pressure necrosis of the duodenal mucosa leading to erosion and fistulation with the distal CBD. Our case brings to light a new and potentially avoidable complication of PEG tubes.
1908 Iatrogenic Severe Rupture of the Spleen Following Colonoscopy
Authors: Enofe Ikponmwosa , Burch Jacob , Yam Julie
Published: October 2019

INTRODUCTION:

Splenic injury is a rare complication of colonoscopy, with about 100 reported cases worldwide. Identification of splenic injury following colonoscopy is challenging given its non-specific presentation and low incidence. This case report highlights the importance of a high index of suspicion in patients with vague abdominal symptoms post colonoscopy and the need to increase awareness for splenic injury as a possible complication of colonoscopy.

CASE DESCRIPTION/METHODS:

A 72-year-old female presented to the ER with left upper quadrant (LUQ) abdominal pain and weakness 8 hours after a diagnostic colonoscopy. Past medical history included DVT and multiple episodes of PE, for which she was on Coumadin. Coumadin was held prior to colonoscopy. PT and the INR on the day of the procedure were 19.0s and 2.0. Normal findings with no technical difficulties, therapeutic interventions, or biopsies taken during colonoscopy. At discharge, she remained asymptomatic, and Coumadin was resumed. On return, exam revealed normal vital signs and distended abdomen with LUQ tenderness. Labs showed: hgb = 8.1, PT = 15.3s, INR = 1.6, and aPTT = 22.3s. CT revealed peri-splenic fluid collection suspicious for hemorrhage or subcapsular hematoma with free fluid extending into the pelvis. Coumadin was discontinued, and she was managed non-operatively with serial abdominal exams and hemoglobin measurement. Hemoglobin remained stable without requiring blood transfusions. Coumadin was resumed on day 4 and hemoglobin was monitored for another 48 hours, remaining stable at 9.0 g/dl.

DISCUSSION:

Splenic injury is a rare complication of colonoscopy with a reported incidence of 1:6,000 to 1:100,000 colonoscopies performed. Associated symptoms are non-specific with significant variability in timing of onset, posing a diagnostic dilemma for clinicians. Most patients with splenic injury present within 24 hours post procedure. However, some may present after 10–14 days. LUQ abdominal pain is the most common symptom, although in some cases, patients may be asymptomatic. Hypotension, anemia, and elevated white blood cell count may be present as well. Anti-coagulants and anti-platelets have been shown to not increase the risk of splenic injury during colonoscopy. The most accurate test for diagnosing splenic injury is abdominal CT, with a 98 % specificity and sensitivity. Splenic hematoma represents a rare complication of colonoscopy and should be included in the differential for a patient complaining of abdominal pain following the procedure.
1913 A Unique Presentation of Asymptomatic Mantle Cell Lymphoma at Screening Colonoscopy: Beware of a Lumpy-bumpy Mucosa
Authors: Park Sa Ra , Hays R. Ann , Figueroa Esteban J.
Published: October 2019

INTRODUCTION:

Mantle cell lymphoma (MCL) is a rare aggressive subtype of non-Hodgkin’s lymphoma. Most cases of MCL initially present with diffuse lymphadenopathy. The gastrointestinal (GI) tract is involved in 15–30% of cases and can manifest as a rare clinical entity called multiple lymphomatous polyposis (MLP). Because of its rarity, a clinical syndrome of MLP is not well defined and its presentation varies. Prior case reports describe the presence of GI symptoms in patients with MLP. We present an unusual case of an asymptomatic patient who was found to have MLP on screening colonoscopy and subsequently diagnosed with MCL.

CASE DESCRIPTION/METHODS:

A 55 year-old female presented for a screening colonoscopy with a family history of colon cancer. Her last screening colonoscopy 5 years prior was unremarkable. She denied any change in bowel movement, blood in her stool, abdominal pain, chest pain, or shortness of breath. Her CBC and CMP one year prior were unremarkable. At colonoscopy numerous small nodular, submucosal polypoid lesions with a prominent vascular pattern were found in the terminal ileum; the mucosa of sigmoid, descending, transverse, and ascending colon had a diffuse subtle nodular appearance. With narrow band imaging, numerous <1 mm nodules with atypical vascular pattern were visualized. Biopsies of all lesions were obtained for histology and flow cytometry, which confirmed a diagnosis of mantle cell lymphoma. Subsequent laboratory evaluation revealed a normal CBC and BMP, mildly elevated AST and ALT to 40–50s U/L, and an elevated LDH of 400 U/L. PET CT scan demonstrated left cervical lymphadenopathy (up to 1.9 cm), mesenteric lymphadenopathy (up to 1.2 cm), and uptake at the ileocecal junction. She was begun on a regimen of rituximab, cytarabine, and bendamustine by oncology.

DISCUSSION:

This case illustrates an unusual presentation of MLP in that it was discovered in an asymptomatic at time of her screening colonoscopy. It is important to recognize this rare endoscopic entity as early diagnosis and treatment improve the prognosis. The diagnosis of MLP should be considered whenever multiple submucosal polypoid lesions are encountered during endoscopy. Histopathology and flow cytometry are key to confirming the diagnosis; therefore, it is important to submit representative biopsies of these lesions for both histology and cytology to avoid delay in diagnosis, need for repeat procedures, and delay in treatment.
1915 Delayed Post-Polypectomy Bleeding Case Report, Using Cold Snare Technique
Authors: Kutaimy Raya , Ravi Anand K. , Ehrinpreis Murray N.
Published: October 2019

INTRODUCTION:

Most cases of colorectal cancer develop from colorectal polyps, therefore their early detection and removal decreases the risk of colorectal cancer death. Hot snare is the most commonly used endoscopic technique to eradicate colonic polyps with some inevitable post polypectomy bleeding. Cold snare polypectomy has been used recently because of its low risk of immediate and delayed post polypectomy bleeding.

CASE DESCRIPTION/METHODS:

A 66 y/o female with a history of ascending colon cancer status post right hemicolectomy presented for routine screening colonoscopy. She has a history of coronary artery disease status post stenting, systolic congestive heart failure and mechanical aortic valve for which she is on warfarin for anticoagulation. Warfarin was stopped 7 days before the procedure, without bridging. Colonoscopy showed two small polyps in the descending and sigmoid colon, and these were removed using cold snare. She was stable after colonoscopy and was discharged. Warfarin was restarted on the next day. Five days later she presented to the hospital complaining of bright red bleeding per rectum and bright red blood with stool. Hemoglobin had decreased from 11.4 (gm/dl) on the day of admission to 9.8 (gm/dl) the next day. Repeat colonoscopy was performed and a large clot was seen in the descending colon at one polypectomy site. There was no active bleeding from the clot though there was some minimal oozing with manipulation. The clot was not removed due to concerns of a large defect underneath that might bleed again. The surgery team was consulted during the procedure. Both GI and surgery teams decided not to proceed with any intervention. Another small non-bleeding ulcer in the sigmoid colon measuring 5 mm was seen and likely represent the site of previous polypectomy. She was monitored after the procedure, her symptoms and hemoglobin improved. Warfarin was restarted and discharged in stable condition.

DISCUSSION:

Cold snare polypectomy is being increasingly used as it is safe and efficient for small polyp removal. Newer polypectomy snares designed for cold snare polypectomy have been developed. This equipment may further decrease complications from smaller polypectomies. We present a case of rare delayed post polypectomy bleeding with the development of a large post polypectomy ulcer, even though anticoagulation was interrupted 7 days before the procedure. We used the traditional polypectomy snare. Results could have been different if the more modern cold snare polypectomy equipment used.
1918 A Case of Recurrent Pneumatosis Intestinalis and Portal Venous Gas
Authors: Fennell Siobhan , Novak Jeffrey , Marwil Zachary
Published: October 2019

INTRODUCTION:

Mesenteric ischemia (MI) is caused by inadequate blood flow through the mesenteric vessels resulting in ischemic bowel. The most serious cases cause gangrenous bowel, leading to pneumatosis intestinalis (PI) and portal venous gas (PVG), often an ominous sign.

CASE DESCRIPTION/METHODS:

This is a case of a 63-year-old male who presented to the hospital with hematemesis and severe anemia. After massive transfusion, an EGD revealed actively bleeding gastric ulcers, requiring serial EGDs for successful control of bleeding. A CT revealed gastric distention with thickening of the duodenum and bilateral femoral vein opacities, later confirmed as deep vein thromboses. An IVC filter was subsequently placed, as he was not a candidate for anticoagulation. The patient was subsequently discharged on oral pantoprazole. Of note, there was no history of NSAID use or evidence of H. pylori. Repeat EGD 2 months later noted mild gastritis, but no ulcers were seen. A screening colonoscopy at the time noted only diverticulosis. He was continued on pantoprazole. 3 months later he presented to the hospital with acute onset nausea, vomiting, and diarrhea. A CT revealed PI at the gastric fundus, as well as PVG. An infectious work-up was negative, lactate was normal, and his symptoms resolved quickly. A subsequent repeat CT noted resolution of the PVG and reduction in PI. He represented to the hospital 1 month later again with nausea, vomiting, and diarrhea. A CT noted small bowel dilatation with air fluid levels, PI at the esophagus, stomach, and jejunum, and significant PVG. The initial lactate level was mildly elevated and his symptoms resolved quickly after bowel decompression. A subsequent CTA noted a significant reduction in PVG without evidence of vascular occlusion. A follow up EGD showed diffuse subepithelial hemorrhages without any evidence of recurrent ulcers. A subsequent CTE noted a thrombus above the IVC filter and an evolving hepatic infarction. He was asymptomatic at the time, however, he was admitted to the hospital for anticoagulation. He has since remained on warfarin without any recurrence of symptoms, PI, or PVG. A follow-up CTA showed a full resolution of venous thromboses.

DISCUSSION:

Previous case reports have described the development of PI and PVG secondary to underlying MI. This case highlights an example of MI secondary to an increase in the resistance of mesenteric blood flow due to venous thromboses. When investigating IP and PVG, underlying venous thromboses should always be considered.
1928 A Rare Case of Hematemesis Due to a Large Gastric Pyloric Gland Adenoma
Authors: Boston Iman J. , Chen Patrick , Wille R. Christopher
Published: October 2019

INTRODUCTION:

Accounting for less than 3% of all gastric polyps, pyloric gland adenomas (PGAs) are rare tumors that usually arise from the stomach or, less commonly, the esophagus, duodenum, pancreas, or gallbladder. PGAs rarely cause symptoms and hematemesis as the presenting symptom has not been previously described in the literature. We present a rare case of hematemesis secondary to a large gastric PGA.

CASE DESCRIPTION/METHODS:

A 94 year-old female with a history of hypothyroidism and occasional nonsteroidal anti-inflammatory drug-use presented with hematemesis and hematochezia. She complained of acute-onset nausea, vomiting and diarrhea. Patient was hemodynamically stable at the time of presentation. Admission laboratory studies were significant for a hemoglobin of 7.2 mg/dl compared to 11.4 mg/dl two weeks prior. An esophagogastroduodenoscopy (EGD) was performed and revealed a 4 cm polyp-appearing mass with a short stalk in the mid-greater curvature of the body of the stomach. The tissue was friable and spontaneously bled with minimal friction from the snare, thus likely the etiology for the patient’s symptoms. The polyp was removed in piecemeal fashion using hot snare. Submucosal epinephrine was injected and four DuraClips were deployed over the polypectomy site. The patient declined to undergo a colonoscopy. Following her EGD, patient did not exhibit any additional signs or symptoms of continued bleeding and was discharged home in good condition. Pathology revealed pyloric gland adenoma with high-grade dysplasia.

DISCUSSION:

This case emphasizes the need for increased awareness regarding the presence of PGAs. These lesions have been shown to arise in chronically damaged mucosa and were associated with autoimmune gastritis in 33.9% of patients, active Helicobacter pylori-associated gastritis in 30.2% of patients, and normal gastric mucosa in only 3.8% of patients. Patients are usually elderly females with an average age of 75 years; though signs and symptoms are variable, laboratory evaluation frequently reveals anemia. This diagnosis is rare but the malignant potential was reported between 12 to 30% of cases in two large studies making improved classification and management necessary.
1932 The Answer Is on Your Skin: A Case of GI Bleeding Secondary to Kaposi Sarcoma
Authors: Penninti Pranav , Haddad Nael , Malakouti Mazyar , Camero Alfredo , Wright Randy P.
Published: October 2019

INTRODUCTION:

GI tract bleeding in AIDS patients carries with it a significant degree of morbidity, with a unique differential including different opportunistic infections and malignancies. Kaposi Sarcoma (KS) is a form of malignancy associated with the human herpes-virus 8, recognized as an AIDS defining illness, and is typically recognized by violaceous cutaneous lesions. KS can also have widespread involvement of the visceral organs including the GI tract, where it can manifest as anything from GI bleeding to diarrhea, abdominal pain, nausea/vomiting and weight loss. Here, we describe a case of AIDS-related KS leading to profound GI bleeding.

CASE DESCRIPTION/METHODS:

A 29 year old male with a history of AIDS (CD4 of 44 cells/mm3and viral load of 18,000 copies/mL) in the setting of anti-retroviral therapy (ART) non-compliance presented with subacute onset shortness of breath, palpitations and malaise over the prior week. Upon review of systems, he endorsed diarrhea and melena over the same timeframe, while denying any other GI tract symptoms. Vital signs on presentation were significant for tachycardia to 103 bpm. Physical exam was notable for violaceous small lesions in buccal mucosa, hard palate, arms and back. His initial labs indicated severe anemia with a hemoglobin level of 4.9 g/dL with a ferritin level of less than 10 indicating severe iron deficiency anemia. After initial resuscitation, the patient underwent upper and lower endoscopy. His EGD showed multiple small round, heaped up ulcers in the gastric antrum, body, and fundus, along with similar ulcers in the second part of the duodenum. His colonoscopy showed similar lesions found in the transverse colon and rectum as illustrated in the images below. Biopsies taken from those lesions along with skin punch biopsies confirmed the diagnosis of Kaposi Sarcoma. He was discharged on Emtricitabine/Tenofovir and Darunavir/Cobicistat with follow up after several months showing dramatic improvement in his skin lesions and resolution of his gastrointestinal symptoms.

DISCUSSION:

The endoscopic appearance of KS in the GI tract is unique, often appearing as hemorrhagic nodules or plaques, however still requires tissue biopsy for diagnosis. Treatment is centered on ART with the use of systemic chemotherapy typically only needed in case of severe symptoms or lack of response to ART. Our case is a testament to the broad differential to be considered in HIV/AIDS patients with GI bleeding, of which Kaposi Sarcoma should be considered.
1942 A Rare Source of Gastrointestinal Bleeding Discovered With Capsule Endoscopy
Authors: Harris Michael , Settergren Noah , Giang Jimmy , Dionisio Paula
Published: October 2019

INTRODUCTION:

Melanoma accounts for 5% of all skin cancers, with lentigo maligna melanoma (LMM) accounting for 10–15% of melanomas. The LMM variety harbors a risk of invasive progression up to 20%. Studies have shown that the small bowel is a preferred site for melanoma metastasis due to its high vascularity, and approximately 60% of patients diagnosed with melanoma skin cancer will have gastrointestinal (GI) metastasis. The usual time for primary melanoma to GI metastasis is 60–90 months. Metastatic melanoma is a rare cause of GI bleeding but should be considered in all patients with history of cutaneous melanoma. This case report presents a man with history of LMM who presented with melena and capsule endoscopy identified small bowel metastasis of the primary cutaneous melanoma.

CASE DESCRIPTION/METHODS:

A 78-year-old man with medical history of cutaneous melanoma and Mohs surgical resection 2 years prior presented to the emergency department for melena over a 2-week duration. One year before this admission the patient presented with similar complaints and esophagogastroduodenoscopy (EGD) with colonoscopy did not yield a bleeding source. At admission he was hemodynamically stable with a hemoglobin of 9.7. Hemoccult testing in the emergency department was negative, but the patient was admitted for monitoring. Gastroenterology was consulted and because the patient had a stable hemoglobin during his stay without hemodynamic compromise, and in-light of recent negative EGD and colonoscopy, the decision was made to follow-up outpatient with capsule endoscopy (CE). On review of CE footage, the patient was found to have an ulcerated mass with active bleeding in the small bowel. Biopsy confirmed the mass was metastatic melanoma. The patient was referred to oncology who found multiple boney and liver metastases and started him on Nivolumab and Zometa.

DISCUSSION:

Metastatic melanoma spreads to the small bowel in 60% of cases. As in this case, metastatic melanoma to the small bowel can cause an occult GI bleed, or even massive bleeding and hematemesis, with some cases of intussusception also reported. Whatever the presentation, one should have a high index of suspicion of metastasis in patients with a history of cutaneous melanoma and new GI bleeding. Negative EGD and colonoscopy should prompt an investigation with CE to rule out metastatic lesions.