bluuebunny/crossref_metadata_2025 huggingface dataset:
1804 An Unusual Presentation of Mallory-Weiss Syndrome (MWS)
Authors: Pacha Faris , Skrove Jamie L. , Mohan Karthik , Sobrado Javier , Rana Zaid
Published: October 2019

INTRODUCTION:

Mallory-Weiss syndrome (MWS) is characterized as longitudinal mucosal tears of the esophagus, most often located in the gastro-esophageal junction that may extendproximally into the distal and even mid- esophagus or distally into the stomach. Risk factors for bleeding as a result of a tear include alcohol abuse and concomitant portal hypertension. Incidence is highest among the male gender and between the ages of 40-60. The proposed mechanism of the tearing is an increase in intra-abdominal pressure leading to a tear through the mucosa and underlying esophageal venous and/or arterial plexus. We present a unique case of MWS that originated in the mid-esophagus with no extended involvement of the distal esophagus.

CASE DESCRIPTION/METHODS:

A 51-year-old male with a past medical history of alcohol dependence presented to the ER for hematemesis. In the ER, the patient’s respiratory status rapidly declined and the patient was intubated. The lab values and chest xrays were all normal. After intubation, the patient continued with heavy retching that contained frank blood and clots. Emergent endoscopy was performed and a large mid-esophageal Mallory Wiess tear was identified and treated with epinephrine injections. There was also an ulceration of the GE junction that was treated with epinephrine and hemoclip placement. The patient recovered without further incident and was discharged several days later.

DISCUSSION:

Initial management of MWS with concomitant upper GI bleed includes: airway management, IV PPI, IV antiemetic, and upper endoscopy for evaluation of the tear with therapeutic interventions that may involve thermal coagulation, hemoclips, epinephrine injection, and/or band ligation. Complications often occur if bleeding cannot be controlled, and surgery may ultimately be necessary. As mentioned, MWS usually involves the gastro-esophageal junction. In a literature review, no previous cases involving a tear limited solely to the mid-esophagus were described until now. It is unclear as to what the pathophysiology behind this particular presentation is or if the location of the tear changes the prognosis and/or complication rate of the case. With no previous cases to review, recommendations are limited; however prompt management remains vital for all MWS cases.
1812 Upper Esophageal Stenosis Secondary to Multiple Foreign Body Ingestions
Authors: Hitawala Asif , Alomari Mohammad , Al Momani Laith , El Kurdi Bara , Sanaka Madhusudhan R.
Published: October 2019

INTRODUCTION:

Multiple episodes of foreign bodies ingestion and subsequent esophagogastroduodenoscopies (EGDs) can lead to an uncommon and disabling complication- esophageal stenosis. We present an interesting case of recurrent foreign body ingestions complicated by upper esophageal stenosis making further foreign body retrieval difficult.

CASE DESCRIPTION/METHODS:

A 33-year-old female with a past medical history of borderline personality disorder, impulse control disorder and recurrent non-suicidal foreign body ingestions requiring multiple EGDs and surgeries presents to the emergency department after ingesting a battery. On arrival, she complained of trouble swallowing, chest pain and abdominal pain. Physical examination was remarkable for abdominal tenderness and guarding. Laboratory results showed hemoglobin of 8.4 gm/dl and hematocrit of 27.8%. Plain radiography of the chest and abdomen revealed a radiopaque tubular device overlying the stomach (Figure 1a) and a cylindrical radiopaque foreign body overlying the left upper quadrant over the stomach (Figure 1b), respectively. Patient was intubated and scheduled for an EGD. During the procedure, the patient was noted to have scarring and granulation polyp in the mid esophagus. (Figure 2) A battery was found in the gastric body and removed via a snare. During retrieval, the cricopharyngeus muscles were found to be tight and did not enable the passage of the battery. That required the use of Miller blade to open up the pharynx to enable safe passage. Battery was intact on removal. (Figure 3) The patient tolerated the procedure well and was discharged home after a period of observation.

DISCUSSION:

Foreign body ingestion and subsequent endoscopic procedures are associated with a variety of complications, including perforation, bleeding and infection. Those complications may result from the sedation as well as the diagnostic and therapeutic maneuvers performed. Our patient had a history of multiple foreign body ingestions, including knives and razor blades, requiring multiple EGDs for their removal. These together led to scarring of her esophagus with subsequent healing and contraction, resulting in esophageal stenosis. This warranted additional intervention and multidisciplinary approach for safe removal of the foreign body. Given the risk of esophageal stenosis in patient with recurrent foreign body ingestions, endoscopists should keep this complication in mind and be prepared with the needed equipment.
1816 Achalasia in the Setting of Esophageal Varices Achalasia in the Setting of Achalasia in the Setting of Esophageal Varices
Authors: DuBroff Jason , Bank Jeffrey S. , Fang John C. , Gawron Andrew J. , Byrne Kathryn R.
Published: October 2019

INTRODUCTION:

Primary achalasia is an esophageal motility disorder characterized by inadequate or absent lower esophageal sphincter (LES) relaxation and loss of normal esophageal peristalsis of the esophageal body. We present an unusual case of achalasia in the context of esophageal varices, creating a challenging therapeutic dilemma.

CASE DESCRIPTION/METHODS:

A 63-year-old male with a history of hypertension, type II diabetes, decompensated HCV cirrhosis (status post sofosbuvir/velpatasvir and ribavirin without sustained virologic response) with hepatic encephalopathy, initially presented with a five month history of progressively worsening dysphagia, unintentional 40 lb. weight loss, and epigastric abdominal pain. He underwent an EGD with findings highly suspicious of achalasia with dilated esophagus, a large amount of retained food with associated stasis esophagitis, hypertonic LES, and no obvious esophageal varices. Esophageal manometry confirmed absence of normal contractility and elevated integrated relaxation pressure (29 mm Hg) consistent with Type I achalasia. On subsequent EGD, he was noted to have grade II esophageal varices. Treatment of achalasia was performed with botulinum toxin injections of the LES, carefully avoiding the esophageal varices. In the next 48 hours, he had significant improvement in symptoms of dysphagia, tolerated a full liquid diet, and then underwent a repeat EGD with successful decompression of his varices with placement of two bands. He was discharged from the hospital tolerating a regular diet.

DISCUSSION:

Achalasia is uncommon, with an annual incidence of approximately 1 in 100,000 individuals. Achalasia in combination with esophageal varices is a very rare occurrence with only 12 case reports and one retrospective study of 14 patients in the current published literature. This particular disease combination presents a therapeutic challenge as our patient was a poor candidate for surgical myotomy given his cirrhosis and bleeding risk. Our case is consistent with previously documented reports showing short-term clinical improvement with botulinum toxin injections as a well-tolerated first line therapy.
1820 Dysphagia Lusoria: When Surgery Is the Bitter Pill to Swallow
Authors: Werlang Monia Elisa , Paniz Graziella Rangel , Brahmbhatt Bhaumik
Published: October 2019

INTRODUCTION:

Aberrant subclavian artery (ASA) is a rare anatomic variant and frequently asymptomaticcondition. We present a case of a young patient with progressive dysphagia who underwent extensive workup and repetitive endoscopic procedures until diagnosed.

CASE DESCRIPTION/METHODS:

35-year-old female with history of systemic lupus erythematous, presented with progressive dysphagia for several weeks. No preceding trauma, procedures or infections. She had anunremarkable upper endoscopy, but an empiric esophageal dilation was performed. However, in few months her symptoms recurred; another dilation was pursued along with proton pump inhibitor therapy and dietary changes.

Three years later, she had worsening dysphagia, leading to an 8-pound weight loss. An esophagram raised suspicion for an extrinsic esophageal compression (Figure 1). A computed tomography (CT) angiogram confirmed the presence of a right ASA (Figure 2).

Patient was referred to thoracic surgery and underwent operative repair of right ASA (Figure 3). A repeated esophagram on the 5th day after surgery, showing no delay in the passage of the barium pill. Upon discharge, she was tolerating soft diet and in one month she was able to eat normally.

DISCUSSION:

ASA is characterized by a vascular ring structure due to aberrant arising of one of the subclavian arteries (arteria lusoria) from the aortic arch. Although ASA is the most common congenital aortic arch anomaly, it occurs in less than 2.5% of overall population. Its management depends on symptoms: if mild and intermittent, dietary and behavioral modifications are appropriate; if severe dysphagia, surgery should be considered. During adulthood, 30% of patients are symptomatic with intermittent dysphagia being the most prominent symptom. Late presentation is probably related with atherosclerosis and aneurismal formation due to advancing age. Even though ASA is found mostly in women and its possible relation with atherosclerosis, we could not find any data in literature linking ASA to SLE. Dysphagia lusoria can be easily diagnosed by barium esophagogram, an inexpensive test which would typically show an impression defect at the level of the third or fourth vertebra. Esophageal manometry and upper endoscopy usually are unrevealing but a CT angiogram can confirm the diagnosis. Because of its rarity, ASA is not commonly suspected upon evaluation of dysphagia in adults, often times causing recurrent endoscopies and other non-revealing tests to be repeated.
1830 Granular Cell Tumor as a Rare Cause of Dysphagia
Authors: Moore Andrew , Lee Salina , Jakate Shriram
Published: October 2019

INTRODUCTION:

Granular cell tumors are a rare cause of dysphagia and dyspepsia. While rare and difficult to detect, diagnosis and resection of GCTs can often provide symptomatic relief in patients. We present a case of a patient with chronic dyspepsia and dysphagia, with a seemingly incidental finding of an esophageal granular cell tumor.

CASE DESCRIPTION/METHODS:

Patient was a 32-year-old female with a past medical history significant for SLE-Sjogren’s overlap syndrome who presented to the GI clinic for a follow-up appointment with new complaint of dysphagia for two weeks. Patient was evaluated one year prior with complaints of nausea, vomiting, and dyspepsia which was managed with levbid and amitripyline; however, she continued to have symptoms of epigastric abdominal pain. Physical exam was unremarkable. Given continued epigastric abdominal pain and now dysphagia, PPI was increased to twice daily. Repeat EGD showed a nodule in the esophagus, and pathology was consistent with granular cell tumor (GCT) (Figure 1). Patient underwent endoscopic ultrasound (EUS) which showed a sub epithelial 7x3mm hypoechoic nodule in upper third of esophagus within the luminal interface/superficial mucosa and deep mucosa (Figure 2). Patient underwent endoscopic mucosal resection (EMR) of the nodule one month later. On histological evaluation, the resection appeared complete, but there was one margin with tumor extending to the margin, so there was a plan for the patient to repeat EUS/EGD in six months. At six month follow-up, her dysphagia had resolved and her functional abdominal pain had improved enough to allow decreasing her medication requirements.

DISCUSSION:

Thought to originate from Schwann cells, GCTs are extremely rare tumors that can occur at any anatomical location. Nestin expression in GCTs indicates that they may arise from a common stem cell in the GI tract, which can differentiate along both interstitial cells of Cajal and peripheral nerve pathways, leading to the common abdominal symptoms of abdominal pain, distention, and dysphagia. Decision for removal is determined based on size, with those less than 1 cm in diameter usually being treated conservatively, and those greater than 1cm typically removed, regardless of symptoms, due to increased incidence of malignancy. Our case highlights that GCTs are a rare cause of non-specific abdominal symptoms and of dysphagia but should be considered in all middle aged patients presenting with these symptoms.
1835 Closure of a Large Gastroesophageal Anastomosis Leak With Endoscopic Suturing After the Failure of Stent Therapy
Authors: Khan Ahmad , Chowdhry Monica , Sohail Abdullah , Singh Shailendra
Published: October 2019

INTRODUCTION:

Gastroesophageal anastomotic leaks remains a potentially life-threatening post-esophagectomy complication. Surgical repair or conservative therapy have been used traditionally with suboptimal outcomes. Endoscopic methods are now an effective alternative to surgery for the management of anastomotic leak. We report a case of closure of a large Gastroesophageal anastomotic leak using a combination of endoscopic suturing with OverStitch (Apollo Endosurgery, Austin, Texas, USA) and esophageal stent after patient failed to respond to esophageal stent alone.

CASE DESCRIPTION/METHODS:

A 49-year-old male with a history of adenocarcinoma of distal esophagus underwent distal esophagectomy and placement of a percutaneous gastrostomy tube. The postoperative course was complicated by sepsis and empyema. Broad-spectrum antibiotics were started, and a percutaneous drain was placed in the mediastinum for drainage of empyema. EGD was then performed by the surgical team, which led to the identification of dehiscence of the gastroesophageal anastomosis and leak. A fully covered, 23 mm by 105 mm esophageal metal stent was placed. The patient was not able to tolerate liquids orally and continued to complain of nausea and vomiting. He continued to have a large amount of drainage from the mediastinal percutaneous drain. Repeat esophagram 8 weeks post op revealed persistent leak at the anastomosis (Figure 1). Gastroenterology was then consulted for endoscopic closure of the leak. Endoscopy was performed, and the fully covered metal stent was removed. Endoscopic examination after stent removal revealed a gastroesophageal anastomosis defect about 20 mm in diameter with necrotic appearing mucosa at the site of the leak (Figure 2). The anastomotic defect was then successfully closed with approximating the healthy gastric and esophageal mucosa. A figure-of-8 pattern of endoscopic sutures was placed using the Apollo OverStitch device. Another layer of reinforcement sutures was also placed. One fully covered 23 mm by 105 mm esophageal stent was placed over the anastomosis. The patient was started on a clear liquid diet. Esophagram performed on day 5 (Figure 1) showed no anastomotic leak. Diet was then further advanced, and the patient was discharged home.

DISCUSSION:

Large gastroesophageal anastomotic leak remains a potentially life-threatening complication post-esophagectomy. Patients failing stent therapy usually with large leaks can be successfully treated with a combination of endoscopic suturing and stent placement.
1838 Esophageal Leukoplakia
Authors: Hernandez Patricia V. , Snyder Diana L. , Kahn Allon , Wang Kenneth K. , Katzka David A. , Horsley-Silva Jennifer L.
Published: October 2019

INTRODUCTION:

Epidermal metaplasia is a histological correlate to a white patch on the surface of a mucous membrane that cannot be rubbed off, known as leukoplakia. It is a common finding in oral mucosa, however rare in esophageal mucosa. Etiology of this condition in the esophagus is unclear, thought to be associated with esophageal tobacco and alcohol exposure or possibly an unusual response to chronic acid reflux. In contrast to oral leukoplakia there is a female predominance. Although generally asymptomatic, symptom presentation can include dysphagia. Endoscopic features include slightly elevated whitish surface, which can be translucent or cobblestone-like in appearance. The natural history is unknown though there is concern for an increased risk of squamous cell cancer. Due to paucity of published studies about this condition, we aim to report a case treated with endoscopic submucosal dissection (ESD).

CASE DESCRIPTION/METHODS:

A 64-year-old Caucasian man with a history of tobacco use and stable weight, presented to Gastroenterology clinic due to an 11-month history of solid food esophageal dysphagia. Physical examination was unremarkable. Upper endoscopy demonstrated white plaques at the gastroesophageal junction (Figure 1A and B). Biopsies obtained from this abnormality showed esophageal epidermoid metaplasia consistent with leukoplakia and mild patchy active chronic inflammation. GMS stain for fungal organisms was negative. An ESD procedure was planned, due to lesion size to ensure complete removal. Chromoscopy with methylene blue was used to mark the borders of the lesion and ESD was accomplished without adverse events (Figure 1C). Histologic examination confirmed hyperplastic squamous esophageal mucosa with marked hyperkeratosis without dysplasia and negative margins. During 2 year follow up, patient reported complete resolution of his dysphagia.

DISCUSSION:

The management strategy for esophageal leukoplakia is not well defined though reports suggest that endoscopic resection and surveillance are warranted. Here we represent a case where symptoms resolved and the lesion was completely removed by ESD.
1839 From the Lap to the Lung: The Esophagus Is the Answer
Authors: Chung Erica , Advani Rashmi , Baron Sarah
Published: October 2019

INTRODUCTION:

Esophageal pathologies are significant yet under-reported complications of laparoscopic adjustable gastric banding (LAGB). We report a case of LAGB-associated esophageal dilatation and dysmotility that resulted in multifocal aspiration pneumonia (PNA) and a lung abscess 8 years after LAGB.

CASE DESCRIPTION/METHODS:

A 48-year-old morbidly obese man who underwent LAGB in 2011 presented with productive cough, dyspnea, and pleuritic chest pain for 3 weeks. He also reported intermittent postprandial gastric reflux and regurgitation of food since his LAGB, which he had been managing with lifestyle modifications. In the Emergency Room, he was febrile to 102F with leukocytosis to 16.8k/uL. CT chest revealed a fluid-filled esophagus (Figure 1) and a thick-walled cavity in the right lower lobe with an air-fluid level, consistent with a lung abscess (Figure 2). Additional consolidations were seen in the bilateral upper lobes. An esophagram was done due to a suspicion for aspiration PNA, and this confirmed a dilated distal esophagus (Figure 3) with impaired peristalsis and nonpropulsive contractions indicative of dysmotility. The patient’s esophageal pathologies and multifocal PNA were determined to be complications from his LAGB. He completed 3 weeks of antibiotics and was discharged with bariatric follow up for revision or removal of his LAGB.

DISCUSSION:

LAGB has several advantages over other bariatric procedures including band adjustability, reversibility, and small surgical risk. Despite this, the prevalence of LAGB has declined significantly due to several long-term complications including esophageal pathologies. In fact, one study reported esophageal dysmotility in 68% and esophageal dilatation in 25% of patients 5-7 years after LAGB. Esophageal dilatation is thought to occur from an overly tight band and in patients who overeat and use their distal esophagus as a food reservoir. This results in unsynchronized esophageal contractions and, thus, dysmotility. These patients may report reflux, vomiting, and regurgitation, which put them at high risk for aspiration PNA and, more rarely, complications such as lung abscesses. Patients who present with aspiration PNA or lung abscesses require antibiotics, but esophageal pathology alone should lead to consideration of band deflation or removal in order to prevent future recurrences. This case of LAGB-associated esophageal dysfunction highlights the importance of long-term monitoring of LAGB patients, especially in the setting of continued reflux or regurgitation.
1848 Chronic Diarrhea Complicated by Hyponatremia as a First Clue to Establish the Diagnosis of Pellagra
Authors: Wu Lesley , Disla Jenny Placido , Laskova Violetta
Published: October 2019

INTRODUCTION:

We report a case of middle age man with a history of chronic alcohol abuse, who presented with chronic diarrhea for a month resulted in moderate to severe hyponatremia and was diagnosed with a rare in Western World disease of Pellagra.

CASE DESCRIPTION/METHODS:

This is a relatively young man 49yo with long history of alcohol abuse, who presented with mainly GI symptoms of nausea, non bloody vomiting, watery diarrhea for a month, abdominal pain, and leg rash. Blood work was significant for hyponatremia (121), thrombocytopenia (133), and alcohol level of 87.5. The physical exam was significant for erythematous, dry rash with areas of desquamation on both legs, associated with pruritus and LLQ tenderness. He was evaluated by MICU team, treated for moderate to severe hyponatremia in ER with IV fluids and admitted to medical floor for chronic diarrhea and LE rash workup. Patient has been evaluated by dermatology and Pellagra with other nutritional deficiencies vs Tinea was suspected. He underwent a punch biopsy and started on niacin as well as urea 40% cream. Pathology was consistent with nutritional deficiencies (i.e. zinc, niacin). After careful compilation of all parts of history, physical exam, and pathology, patient was diagnosed with Pellagra and continued on niacin supplementation with resolution of diarrhea and improvement of skin appearance.

DISCUSSION:

Pellagra is a nutritional disorder that results from inadequate intake of niacin or its precursor, the essential amino acid tryptophan. Pellagra is a disease very nearly eradicated in US and Europe except sporadic cases in at-risk groups (chronic alcoholism, malnutrition, malabsorption. It is classically described by the 3 D’s “diarrhea, dermatitis, and dementia”. While the life threatening presentation of Pellagra is very uncommon nowadays, the most severe cases are usually presented as encephalopathy. In our case patient presented with chronic diarrhea, which caused almost life threatening hyponatremia. Diarrhea as the first presenting symptom along with characteristic rash and history of chronic alcohol leaded to diagnosis of Pellagra, the disease easily treated with prompt administration on niacin. Pellagra is mostly a clinical diagnosis and careful collection of all parts of history and physical exam required to early recognize the disease and initiate a niacin intake. Physicians should have a high index of suspicion in certain groups of patients to early diagnose and cure this potentially fatal but treatable disease.
1865 Gastric Perforation During PEG Tube Placement in ALS Patient With Severe Malnutrition
Authors: Gupta Kapil , Marcus Akiva
Published: October 2019

INTRODUCTION:

The natural progression of amyotrophic lateral sclerosis (ALS) usually leads to malnutrition because of decreased oral intake from dysphagia, reduced salivation, and anorexia. A decrease in weight of 5-10 kg or BMI < 20 requires intervention to improve nutrition. Intervention includes placing a feeding gastrostomy surgically, endoscopically (percutaneous gastrostomy or PEG), or radiologically. Complications range from dislodgement to parietal necrosis and death. This case involves a patient with severe malnutrition who had a significant gastric perforation during PEG tube placement, which we attribute to a patient’s nutritional status and mucosal/muscular atrophy.

CASE DESCRIPTION/METHODS:

80 yr-old man with PMH of end-stage ALS presented to the hospital for failure to thrive and significant weight loss. He underwent an EGD for PEG tube placement. During the EGD, the gastric body was notable for diffuse atrophic mucosa and hiatal hernia. Using standard technique, a 20 Fr EndoVive Safety gastrotomy tube was safely pulled through the mouth using guidewire into the stomach. The trocar needle was removed, and the PEG was pulled out from the stomach through the skin. When confirming position of the PEG tube by relook endoscopy, we found a 4 cm perforation in the stomach at the diaphragmatic hiatus with associated hemorrhagic mucosa. At which point, a large amount of subcutaneous emphysema was seen in the chest and neck. The gastroscope was immediately withdrawn, and surgery was called. The patient was transferred to the ICU. After a discussion with surgery, patient, and his family, they agreed to palliative care as patient adamantly refused further procedures. The patient was transferred to hospice care and expired three days later.

DISCUSSION:

This case is a rare presentation of a severe complication during PEG tube placement that we attributed to the poor nutritional status of the patient. We believe that the gastric mucosa and muscular atrophy from severe malnutrition led to the large perforation when the guidewire or the internal bumper of the PEG transversed the diaphragmatic hernia. This is the first case describing a complication of PEG tube placement in a severely malnutritioned ALS patient. In conclusion, this case highlights the possibility of altering procedural techniques for PEG tube placement and the necessity for increased caution during PEG tube placement in ALS patients with severe malnutrition.
1873 Colonic Perforation and Pneumothorax: Rare Complications of Upper GI Endoscopy
Authors: Shah Maulik , Truscello David , Itidiare Michael , Walters Richard
Published: October 2019

INTRODUCTION:

Esophagogastroduodenoscopy (EGD) is a commonly performed diagnostic and therapeutic procedure with a low risk of adverse events, which can include cardiopulmonary events, hemorrhage, infection and perforation. Perforation can occur at the esophagus, stomach or duodenum, leading to pneumoperitoneum. However, what follows is a unique case of a patient who suffered a colonic perforation and pneumothorax after undergoing EGD.

CASE DESCRIPTION/METHODS:

A 71-year-old male presented with a 4-month history of epigastric pain, nausea and weight loss. His medical history was notable for coronary artery disease, hypertension, and chronic obstructive pulmonary disease. On exam, he exhibited epigastric tenderness without rebound, rigidity or guarding. CT scan showed wall thickening of the second portion of the duodenum. Magnetic resonance cholangiopancreatography showed biliary ductal dilatation without definitive obstructive lesion. EGD revealed pangastritis with nodular-appearing, edematous, and hyperemic gastric folds along with thickened duodenal folds, concerning for malignancy. At the completion of the procedure, the patient developed tachycardia and crepitus in his anterior chest wall extending into his neck. A flat plate indicated free intraperitoneal air. Repeat CT imaging discovered a large right-sided pneumothorax and a chest tube was placed. Exploratory laparotomy revealed extensive tumor burden within the mesentery of the large and small bowel with a perforation at the anterior portion of the transverse colon, which was resected with ostomy creation. Pathology was remarkable for invasive colon adenocarcinoma.

DISCUSSION:

While cases of large bowel perforation after colonoscopy are known, we found only one documented case following EGD involving a patient with pneumoperitoneum caused by a perforated sigmoid diverticulum. For our patient, pathology found that the malignancy had eroded through the lumen of the transverse colon. It is suspected that manipulation of the upper GI tract caused perforation of the transverse colon due to fibrosis in the mesentery and adhesions due to omental “caking” from extensive tumor burden. Since our patient’s injury occurred in the transverse colon, air from the perforation was able to travel to the mediastinum via fenestrations in the diaphragm which allowed air to enter the pleural space. Colonic perforation with pneumothorax is a rare complication after EGD and should be kept in mind by practitioners when the EGD shows friable tissue concerning for malignancy.
1874 Atypical Polyp Within a Diverticula: A Hidden Cancer Copycat
Authors: Shen Helen M. , Lee Brian T. , Idos Gregory
Published: October 2019

INTRODUCTION:

Inflammatory granulation polyps inside of a diverticulum are rarely reported in the literature. We report a case of a large inflammatory granulation polyp, which appeared to be a malignant polyp discovered inside of a diverticulum.

CASE DESCRIPTION/METHODS:

A 65-year-old Hispanic female with a history of diverticulosis was referred from her primary care provider for a colonoscopy. The patient reported significant weight loss over the past year and had laboratory evidence of iron deficiency anemia (hemoglobin 11.7 g/dL, mean corpuscular volume 73.4 fL, ferritin 20 ng/mL, iron saturation 12%, TIBC 400 ug/dL). Prior records indicated that the patient underwent a colonoscopy that revealed multiple polyps within her colon. Given her worrisome presentation, a colonoscopy was performed. The colonoscopy was notable for three polyps as well as diverticulosis of the sigmoid colon. Two of the polyps were removed easily and returned as tubular adenoma. However, the third polyp was a large 10-millimeter raised lesion found inside of a diverticulum. The mucosa of the lesion was friable with a central ulcerated indentation, concerning for malignancy. Histology was notable for numerous blood vessels, neutrophils, lymphocytes, plasma cells, and reactive fibroblasts, consistent with an inflammatory granulation polyp. The patient was referred to colorectal surgery for further evaluation in the setting that endoscopic mucosal resection may not be plausible.

DISCUSSION:

Granulation polyps are more commonly observed in the setting of inflammation, such as inflammatory bowel disease, as well as in response to other insults such as infectious or ischemic etiologies. These polyps are difficult to distinguish from a neoplasm. Morphologically, they appear friable with overlying ulceration and exudate, mimicking submucosal invasive cancer. Similarly, our polyp had a classic appearance of malignancy as a sessile polyp with a centrally ulcerated indentation, concerning for submucosal invasion. Given the location of this polyp inside of a diverticulum, polypectomy may be technically challenging. Removal can be associated with an increased risk of bleeding or bowel perforation. There is no data regarding the malignant potential of these polyps in the setting of diverticulosis, although in the setting of inflammatory bowel disease, these polyps have intermediate risk. Although diagnosis is based on histology, endoscopists should be aware of this clinical entity and weigh the risks and benefits of resection versus surveillance.
1877 An Unfortunate Turn of Events: A Rare Case of Splenic Hematoma Following Colonoscopy for Post-Polypectomy Bleeding
Authors: Duriseti Parikshit , Alhudairy Maad , Tandon Manish
Published: October 2019

INTRODUCTION:

Post-polypectomy bleeding has been reported to occur in 0.3 to 6.1% of colonoscopic polypectomies. Splenic injury after colonoscopy is a rare complication with a described incidence of less than 0.017%.

CASE DESCRIPTION/METHODS:

A 66-year-old male with a past medical history of hypertension was admitted with post-colonoscopic polypectomy bleed. He underwent a colonoscopy in July 2018 for a history of adenomatous polyps. The colonoscopy revealed multiple non-bleeding polyps (about 15) throughout the large bowel and 8 polyps were removed with endoscopic mucosal resection (EMR). A follow up colonoscopy was performed for resection of the remaining polyps in October 2018. He presented to the hospital one-week post second colonoscopy with acute onset of hematochezia. On presentation, he was afebrile, with HR 64 and BP 108/62. Labs were notable for hemoglobin of 7.1 g/dl (from a baseline of 11 to 12 g/dl) concerning for post-polypectomy bleeding. Colonoscopy repeated after admission showed no active bleeding; a clean based ulcer was noted in the transverse colon at the site of EMR which was the likely source of bleeding. Hospital course was complicated by severe left upper quadrant pain and shock with BP dropping to 70s/40s requiring ICU admission one day after the colonoscopy. He was found to be coagulopathic with an INR of 4.9 requiring vitamin K and FFP. Hemoglobin dropped to 5.3 g/dl and he received a total of 10 units of pRBC transfusions. CTA abdomen/pelvis showed a splenic hematoma measuring 12.3 x 10 x 17 cm. Splenectomy was deferred per surgery recommendations and coil embolization of the proximal splenic artery was successfully performed. He improved clinically after splenic artery embolization and was discharged home with follow-up.

DISCUSSION:

Splenic injury is a potentially catastrophic complication of colonoscopy with a reported mortality of about 5%. Several mechanisms of splenic injury associated with colonoscopy have been described which include difficult procedure, traction on the splenocolic ligament, external abdominal pressure during colonoscopy, perforation of the splenic flexure and direct trauma to the spleen, and traction of adhesions between the spleen and colon. Patient-related risk factors such as abdominal surgeries leading to adhesions, splenomegaly and pancreatitis increase the likelihood of splenic injury during the procedure. With increasing number of cases, further studies are required to re-assess the incidence and risk factors for splenic injury after colonoscopy.
1879 Gastric Xanthoma: A Rare Endoscopic Finding
Authors: Harne Prateek S. , Mukherjee Samiran , Sharma Anuj , Manocha Divey
Published: October 2019

INTRODUCTION:

Xanthoma is defined as a localized lipid deposit within organs that may manifest as papules, plaques or nodules, most commonly in the skin. The extra-cutaneous manifestation is rare and sparsely reported. Gastrointestinal tract xanthomas are rare benign lesions which have been reported in the esophagus, stomach, and duodenum, with the stomach being the most common site in the upper GI tract with a reported incidence between 0.2-0.8% 1,2. Commonly characterized by yellowish-white plaque in the antrum or the pylorus of the stomach, histologically reveals foamy macrophages in the lamina propria3.

CASE DESCRIPTION/METHODS:

We present a case of a 63-year-old female with past medical history most significant for ESRD on hemodialysis, CVA with right-sided residual paralysis, atrial fibrillation on warfarin who was brought in after being found in a comatose state, soaked in her own blood due to a hemodynamically significant painless GI bleed with H/H drop to 3.0/15.0 which required ICU admission. After stabilization, the patient underwent upper GI endoscopy, push enteroscopy and colonoscopy which revealed a non-bleeding gastric ulcer, non-bleeding internal and external hemorrhoids, non-bleeding angioectasias in the duodenum and a 10mm raised mucosal nodule in the gastric antrum which was biopsied which revealed dense infiltrate of foamy macrophages with positive with CD 163 immunostain that expanded the lamina propria consistent with a xanthoma. Additionally, random stomach biopsy revealed chronic gastritis with intestinal metaplasia.

DISCUSSION:

This case allows us to understand the similarity in the appearance of gastric xanthomas and malignancy like signet cell carcinoma as well as study its reported association with dyslipidemias, gastric dysplasias and carcinogenesis, chronic and atrophic gastritis as well as gastritis caused by Helicobacter pylori making it imperative to confirm by histopathology and maintain a close follow up for monitoring its behavior.
1889 Endoscopic Closure of Gastrocolic Fistula Using Hemostatic Clips: A Novel Approach
Authors: Akhavan Shahrzad Anita , Oak Rachana , Sinha Neera , Chum Christopher , Trillo John
Published: October 2019

INTRODUCTION:

Traditionally, surgery is the mainstay of treatment for gastrointestinal fistulas; more recently, however, therapeutic endoscopic stent placement is being explored for high-risk patients. Successful endoscopic closure of these fistulas using hemostatic clips offers the possibility of an alternative, viable approach for patients who are nonsurgical candidates and may benefit from noninvasive endoscopic interventions.

CASE DESCRIPTION/METHODS:

An 82-year-old male with history of peptic ulcer disease, alcohol abuse, and Billroth II gastrojejunostomy >20 years ago was admitted due to bloody diarrhea. Physical examination was unremarkable except for melena. Laboratory testing revealed a hemoglobin level of 4.6g/dL. After resuscitation, upper endoscopy was performed and the patient was found to have a mucosal perforation at the anastomotic site with an adjacent clean-based ulcer (A, B) without active bleeding. The mucosal defect was closed using four hemostatic clips (C). Abdominal CT scan later confirmed a gastrocolic fistula successfully closed with clip placement (D). The patient’s symptoms resolved; his remaining hospital course was uncomplicated.

DISCUSSION:

Intervention during endoscopy precluded the need for surgical intervention in an elderly patient who would otherwise have been a poor surgical candidate. To the best of our knowledge, this is the first use of hemostatic clip placement for closure of a gastrocolic fistula.
1905 Appendiceal Neuroendocrine Tumor in an Inverted Appendix Discovered on Screening Colonoscopy
Authors: Abdallah Abdallah , Karim Ahmed , Alnakshabendi Imad , Alnazkhabendi Ibrahim
Published: October 2019

INTRODUCTION:

Appendiceal carcinoid tumors are the most common appendix neoplasm. Most cases are diagnosed incidentally after an appendectomy. We present a rare case of neuroendocrine neoplasm from an inverted appendix manifesting as cecal polyp seen on a screening colonoscopy.

CASE DESCRIPTION/METHODS:

Patient is a 58-year-old female with no significant past medical history or family history of colon cancer who presented for colorectal cancer screening. She denied any fevers, night sweats, flushing, palpitations, weight loss, abdominal pain, or changes in bowel habits. She denied any prior abdominal surgeries. Patient underwent colonoscopy which revealed internal hemorrhoid, two polypoid lesions in the cecal area measuring 8 mm, and 1.3 cm. A total of 6 mL of normal saline was injected underneath to lift them up and snaring polypectomy technique applied. Endo Clip was applied at the base of the large polyp and the specimen was retrieved and sent to the pathology. Pathology revealed well-differentiated neuroendocrine tumor, grade 1, 0.4 cm, involving submucosa and muscularis propria of probable inverted appendix/appendiceal stump. IHC stains for CDX 2, Pankeratin, Chromogranin, and Synaptophysin were positive. Stains for CK7/CK 20/PAX 8/Vimentin were negative. Patient returned for a follow-up office visit and was doing well after the procedure. She was later referred for a CT abdomen pelvis with contrast which failed to show an appendix, any cecal masses, or other acute intra-abdominal pathologies. Patient was then referred to a general surgeon for further evaluation who recommended a one-year surveillance colonoscopy.

DISCUSSION:

Neuroendocrine tumors are the most common tumor of the appendix. They are typically discovered incidentally from an appendectomy but rarely manifest in an inverted appendix. Additionally, they are usually located in the distal 1/3 of the appendix and for that reason most patients do not present with obstructive symptoms. Management of tumor depends on the size of the tumor. If the carcinoid is < 2 cm, appendectomy is generally sufficient. In this case the tumor was only 0.4 cm and was completely excised endoscopically in the inverted appendix.
1916 Gastrointestinal Stromal Tumor: Cause of Massive Lower Gastrointestinal Bleed in Young Patient
Authors: Rashid Mamoon Ur , Khan Muzammil Muhammad , Ullah Waqas , Zafar Hammad , Hussain Ishtiaq , Hasan Badar , Ur Rehman FNU Asad , Hurairah Abu
Published: October 2019

INTRODUCTION:

Gastrointestinal stromal tumor (GIST) is one of the rare causes of gastrointestinal malignancies. GIST most commonly occurs in stomach. It arises from one of the specialized cells of GI tract, called as Interstitial Cells of Cajal (ICC) and mutations in one of the KIT gene or PDGFRA are responsible for the development of this tumor. We are here presenting a case of massive GI bleed in a very young patient from GIST tumor in small intestine.

CASE DESCRIPTION/METHODS:

26-year-old male presented to ED complaining of having 3–4 bloody bowel movements in the last 2 days. He stated having soft stool mixed with a large amount of bright red blood. Patient denied abdominal pain, nausea, vomiting, recent travel, sick contacts or weight loss. Patient had low systolic blood pressure in the range of 70–80 on admission. Blood pressure was stabilized with IV fluids. Patient dropped hemoglobin during hospitalization to 5.8 and was transfused 7 PRBC’s. CT abdomen w/contrast revealed a circumferential, lobulated proximal ileal small bowel mass measuring 2.3 × 2.2 × 2.9 cm. EGD and Colonoscopy were done initially which showed extensive amount of blood and clots throughout the colon with very limited views of underlying mucosa but terminal ileum was normal in appearance. No active bleeding was noted. General surgery was consulted and resection of the tumor, that appeared to be the source of the bleeding, was performed in the mid ileum. A 5 cm resection of segment of small bowel was done. Pathology report showed GIST tumor. Patient bleeding stopped subsequently after surgery.

DISCUSSION:

GIST most commonly arises in fifth and sixth decades of life. It may be familial or sporadic. Mutations of KIT (80 %) and PDGFRA (10 %) are associated with both familial and sporadic causes. GIST tumors majority of the time are incidental findings but when symptomatic presenting complaints may include abdominal pain and swelling, nausea, vomiting, loss of appetite, or weight loss. Patient may also present with bowel perforation, acute abdomen and peritonitis. Rarely, they present with GI blood loss resulting in symptomatic anemia and hemodynamic instability. Almost 30% of the GIST tumors are malignant with the histological findings including highly cellular spindle cells or epitheloid mesenchymal tumors. The diagnosis is confirmed by immunohistochemical techniques and expression of tyrosine kinase receptor. Treatment for resectable tumors is surgery while those of non-resectable tumors is Imatinib a tyrosine kinase inhibitor.
1919 Hemobilia Due to Cystic Artery Pseudoaneurysm: A Rare Cause of Hematemesis in a Pediatric Patient With Obstructive Jaundice
Authors: Patel Nishaben , Minkoff Nathan , Bahia Gracielle
Published: October 2019

INTRODUCTION:

Hemobilia is a rare cause of upper gastrointestinal (GI) bleeding, especially within the pediatric population. Here we present a case of hematemesis initially presumed to be secondary to a Mallory-Weiss tear in the setting of choledocholithiasis and later found to have hemobilia due to cystic artery pseudoaneurysm. The triad of right upper quadrant abdominal pain, obstructive jaundice and upper gastrointestinal bleed should prompt consideration of hemobilia.

CASE DESCRIPTION/METHODS:

A 16 year old male with history of obesity and gastroesophageal reflux disease presented to the emergency department with severe epigastric pain and hematemesis. Labs were notable for elevated transaminases [AST 347 (U/L), ALT 422 (U/L)] and conjugated hyperbilirubinemia [direct bilirubin 2.6 (mg/dL), indirect bilirubin 0.3 (mg/dL)]. Abdominal ultrasound showed a large gallstone with a dilated common bile duct (CBD) dilation (1.1 cm). MRCP was negative for filling defects, but showed mild central intrahepatic and extrahepatic ductal dilation with a large gallstone and debris filling the gallbladder lumen. An EGD was performed and a superficial ulcer was seen in the duodenal bulb and presumed to be the source of bleeding. Due to persistence of hematemesis, transaminitis, and up trending GGT 585 (U/L) and direct bilirubin 3.7 (mg/dL), there was question of a distal CBD obstruction. An ERCP was performed, and fresh blood clots were coming from the ampulla. A cholangiogram showed multiple filling defects in the common bile duct from blood clots. Sphincterotomy and CBD stent placement were then performed. Abdominal CT angiography showed a focal arterial density collection along the posteromedial gallbladder mucosal surface, consistent with a pseudoaneurysm vs vascular malformation. A visceral angiogram demonstrated a pseudoaneurysm arising from the posteromedial wall of the cystic artery with successful cystic artery coil embolization. A laparoscopic cholecystectomy was attempted, but was converted to an open surgery, which removed the gallbladder and a large gallstone. He had an unremarkable recovery.

DISCUSSION:

Hemobilia is an uncommon cause of upper GI bleeding within the pediatric population. Most commonly hemobilia is the result of trauma or iatrogenic from hepatobiliary procedures. Angioembolization is often indicated and followed immediately with surgery. In summary, the triad of right upper quadrant abdominal pain, biliary obstruction and upper gastrointestinal bleed should prompt consideration of hemobilia.
1924 Bleeding Beyond the Line: Anorectal Melanoma as a Cause of Lower Gastrointestinal Bleeding
Authors: Phan Huy , Tabibian James H. , Tan Hongying
Published: October 2019

INTRODUCTION:

Anorectal melanoma is a rare malignancy that can present as hematochezia similar to other gastrointestinal bleeding sources. The diagnosis of anorectal melanoma may be challenging given its rarity, nonspecific presentation, and need for histopathology, but accurate and timely diagnosis is essential given that associated bleeding may not respond to conventional treatments.

CASE DESCRIPTION/METHODS:

An 88-year-old male was admitted for septic shock after being found lethargic at his nursing facility. He was started on intravenous antibiotics and vasopressors and intubated for airway protection. Though slowly improving overall, on hospital day 6, he had 4 episodes of large red clots per rectum. Rectal examination showed bright red blood and a rubbery mass palpable on the posterior rectal wall without visible hemorrhoids. Due to the acute drop in hemoglobin to 6.3 g/dL, the patient was transfused 2 units of packed red blood cells, empirically started on intravenous pantoprazole, and administered parenteral Vitamin K and a dose of desmopressin. Over the next two days, the patient continued to have multiple bowel movements with blood clots requiring additional blood transfusions. Given these findings, the patient underwent flexible sigmoidoscopy.

DISCUSSION:

Flexible sigmoidoscopy revealed a 3 cm ulcerated mass in the distal rectum which involved the dentate line. Endoscopic hemostasis was not feasible, but a biopsy was obtained which showed malignant melanoma invading the lamina propria and muscularis with associated ulceration. Considering the patient's age, clinical status, and advanced dementia, the medical team and unrepresented patient committee agreed that it was ethically appropriate to not pursue further work-up or treatment of the patient's melanoma. Following medical stabilization, the patient was transitioned to home comfort care. This case illustrates a rare etiology of bright red blood per rectum and the importance of additional investigation in the setting of clinically significant anemia and/or inadequate response to conservative measures. Anorectal melanoma, similar to other rare disorders which can mimic internal hemorrhoidal bleeding, frequently requires endoscopic techniques for diagnosis and management. Despite this patient's clinical course and the generally poor prognosis of anorectal melanoma, early diagnosis can allow for surgical excision and/or adjuvant therapies that may provide a potentially curative outcome or delay disease progression and mitigate bleeding complications.