bluuebunny/crossref_metadata_2025 huggingface dataset:
1679 Polyposis With a Mutation in the CHEK2 Tumor Suppressor Gene
Authors: Greenberg Ian , Khan Omar , DePersia Allison
Published: October 2019

INTRODUCTION:

Fifteen to twenty percent of colorectal cancer (CRC) is familial and genetic alterations are commonly encountered. Genetic testing is recommended in patients with a personal history of young onset CRC, significant family history of CRC, or high polyp burden, defined as having greater than 10 adenomas. Mutations in CHEK2 are associated with a variety of cancers, including CRC. However there is limited literature describing CHEK2mutations and polyposis.

CASE DESCRIPTION/METHODS:

A 47-year-old male with a personal history of thyroid cancer was evaluated for a six-month history of diarrhea. Family history was notable for multiple relatives on both sides with thyroid, breast, pancreatic, or colon cancer. Given progressive symptoms and family history, he underwent colonoscopy revealing 15 polyps varying in size, diffusely spread throughout his colon. Pathology revealed three polyps were tubulovillous adenomas with high-grade dysplasia, one polyp revealed focal invasive adenocarcinoma, and the remaining eleven polyps were low-risk tubular adenomas. Given the patient’s age, polyp burden, and complex cancer history, there was high suspicion for a genetic etiology of his thyroid cancer, colon polyps and CRC. He was referred for a genetic evaluation. A multi-gene cancer panel identified a heterozygous mutation, c.1072C > T (p.Gln358*) in CHEK2.

DISCUSSION:

Checkpoint kinase 2 (CHEK2) is a critical tumor suppressor gene that serves as an upstream regulator of p53. In response to DNA damage, CHEK2 prevents cell maturation and progression into mitosis. Malfunctioning leads to uncontrolled cell cycle progression without apoptosis. CHEK2 is a multi-organ cancer susceptibility gene linked to increased risk of breast, colon, thyroid and prostate cancer. In addition to a personal history of young onset colon cancer, the patient had a personal history of polyposis. This case report raises the question of whether CHEK2 is also a polyposis gene as this finding has important implications for carrier screening. Genetic evaluation for CHEK2, along with other CRC/polyposis genes, should be considered in young patients with a high-grade dysplastic adenoma, large polyp burden, or a significant personal or familial cancer history. Screening guidelines remain variable at this time and patients found to have a pathologic CHEK2mutation should receive a multidisciplinary approach for cancer screening. Further studies are needed to evaluate the association of polyposis and CHEK2 mutations.
1680 Endoscopic Cyanoacrylate Glue in an Actively Bleeding Gastric Tumor
Authors: Dike Uzoamaka K. , Mistry Tejal , Thosani Nirav
Published: October 2019

INTRODUCTION:

1 to 5 percent of upper gastrointestinal bleeds are due to tumors and it is not atypical for re-bleeding to occur. Most patients who experience severe hemorrhaging esophageal and gastric tumors die within 12 months. Currently, there are no well-defined guidelines regarding the implementation of cyanoacrylate glue in bleeding gastrointestinal tumors. Our primary aim is to demonstrate a novel technique for achieving hemostasis in an actively bleeding tumor.

CASE DESCRIPTION/METHODS:

A 55-year-old female with no documented past medical history presented with hematemesis. The patient experienced an acute drop of hemoglobin from 10 g/dl to 8 g/dl. The patient reported moderate alcohol use and denied use of NSAIDS. EGD was first performed and revealed a pulsating extravasating tumor. This was followed by the use of EUS to identify the bleeding vessel. Under EUS-guidance, cyanoacrylate glue was then precisely injected to achieve hemostasis.

DISCUSSION:

EUS-guided cyanoacrylate glue injection is a cost-effective therapy that may successfully achieve hemostasis in active tumor bleeds. It can serve as a primary method for hemostasis or when re-bleeding occurs. However, its potential for reduced rates of re-bleeding warrants further investigation.

Watch the video: http://bit.ly/2YdnmbC.
1681 Achieving Hemostasis in a Gastric Tumor With Color Doppler-Endoscopic Ultrasound Guided Cyanoacrylate Glue
Authors: Dike Uzoamaka K. , Mistry Tejal , Thosani Nirav
Published: October 2019

INTRODUCTION:

Up to 5 percent of upper gastrointestinal bleeds are due to tumors and re-bleeding is common. Most patients with severe hemorrhaging esophageal and gastric tumors have a poor prognosis, resulting in death within 1 year. Currently, there are no well-defined guidelines regarding the implementation of cyanoacrylate glue in bleeding gastrointestinal tumors. Our primary aim is to demonstrate a novel technique for achieving hemostasis in a tumor bleed.

CASE DESCRIPTION/METHODS:

A 63-year-old male with a past medical history of smoking, non-insulin dependent diabetes mellitus type 2, and hypertension presented with melena and early satiety. The patient denied the use of NSAIDS and alcohol. Evaluation by EGD demonstrated a gastric tumor with stigmata of recent hemorrhage in the form of a non-bleeding visible vessel. EUS was then used to locate this feeding vessel. Color doppler was then employed to confirm the target vessel and to subsequently guide the precise injection of cyanoacrylate glue into the vessel. The cessation of doppler flow after glue embolization confirmed hemostasis of the feeding blood vessel. During this procedure EUS-FNA was also utilized to extract a sample of tissue for diagnostic purposes with a 19-gauge needle.

DISCUSSION:

Color doppler-EUS guided cyanoacrylate glue injection is a cost-effective therapy that may successfully achieve hemostasis in tumor bleeds. It can be utilized to confirm hemostasis of the targeted vessel after embolization, during an endoscopic procedure. Endoscopic confirmation may reduce the likelihood of re-bleeding and additional procedures, thus, improving the quality of care.

Watch the video: http://bit.ly/2M5YAE1.
1683 Hybrid APC-Assisted EMR: A New Technique to Prevent Polyp Recurrence
Authors: Levenick John M. , Manzo Carl , Maranki Jennifer
Published: October 2019

INTRODUCTION:

The importance of colonoscopy in the prevention of the development of colon cancer is readily recognized. Although there has been a decline in rates of colon cancer, 5% of people continue to develop colon cancer and 2.5% will die from it. Roughly 5% of polyps removed are laterally-spreading lesions (LSL) that are greater than 10mm in size. Most large LSLs are now removed endoscopically which allows for removal on an outpatient basis with an improved safety profile. However, one drawback is the rate of recurrence, quoted at 10–30%. A key aspect to EMR is adequately lifting the lesion using an inert dye such as methylene blue infused solution into the submucosal space with special attention to avoiding extramural injection. It was originally felt that APC fulguration could be used to treat remaining tissue post-EMR. However, recurrence rates using this technique remained high. Resection of 3–5 mm of normal tissue around the site also did not reduce recurrence though simple snare-tip soft coagulation of the edges improved recurrence rates. We hypothesize that high recurrence rates post-EMR polypectomy occur due to microscopic residual disease in the base and edges of the lesion and that using APC to treat the post-EMR site will decrease recurrence rates to less than 5%.

CASE DESCRIPTION/METHODS:

Once the LSL is detected and assessed, the patient is grounded and the ERBE Vio300D system is assembled. A solution of saline and methylene blue is made. Using the needleless waterjet of the Hybrid APC system, the lesion is lifted with an effect of 30–50, helping to prevent extramural injection and allowing for optimal lift. EMR is then performed in typical fashion. We often prefer to use the Endo Cut setting with an effect of 2, cut duration of 1, and cut interval of 4. After the neoplasia has been completely removed, the base and borders are relifted with the needleless waterjet . This additional lift helps to avoid deep mucosal injury. APC is then performed using a flow of 0.8 L/min and 30 watts. The entire base of the site and the circumferential borders of the lesions undergo APC in their entirety. Endoclips can be used to close the post-polypectomy site.

DISCUSSION:

Thus far at our institution, we have used hybrid APC assisted EMR in roughly 50 cases. All of these procedures were tolerated well, and only two of them were complicated by delayed post-polypectomy bleeding. We are hopeful that this method will reduce rates of recurrence and eventually possibly become standard of care for these lesions.

Watch the video: http://bit.ly/2xXmNUC.
1684 Paging Dr. MacGyver: A Novel Approach to Redeploying a Dislodged AXIOS Stent During a Pancreatic Necrosectomy
Authors: Reddy Rekha , Cheung Derrick
Published: October 2019

INTRODUCTION:

Although multiple modalities exist for managing walled off and infected pancreatic necrosis, EUS-guided transmural drainage is often favored due to its minimally invasive and highly effective nature. The AXIOS stent has demonstrated clear superiority over double pigtail and fully covered self-expanding metal stents in this setting. Although the radial force from its wide luminal diameter and its dumbbell shape helps secure the stent in place, stent migration and dislodgement can still occur. Here, we present a case of stent dislodgement during a pancreatic necrosectomy, which was salvaged by stent extraction and endoscopic re-deployment using a stone extraction balloon catheter sheath.

CASE DESCRIPTION/METHODS:

A 68-year-old woman with a medical history notable for prior acute pancreatitis presented to the ED with abdominal pain, nausea, and vomiting. CT Abdomen revealed a large pancreatic fluid collection with surrounding necrosis. She was admitted to the SICU for management of necrotizing pancreatitis, and underwent cystgastrostomy with an AXIOS stent on day 14 of admission. During her necrosectomy one week later, the previously placed AXIOS stent was accidentally displaced into the stomach. The displaced stent was grasped with a rat tooth forceps and removed from the patient. One end of the extracted AXIOS stent was stretched so that it became thin enough to be inserted into an empty stone extraction balloon catheter sheath. The other end was then back-loaded into the larger channel of a double-channel gastroscope. The scope was then re-introduced and advanced into the pancreatic cyst cavity. A rat tooth forceps was inserted into the instrument channel and used to advance the back-loaded stent forward, re-deploying the stent under endoscopic guidance only, such that it again traversed the cystic cavity and stomach. The stent was then adjusted into its desired position using rat tooth forceps.

DISCUSSION:

As Interventional Endoscopy’s technologies continue to evolve, it will become increasingly important for the skilled endoscopist to understand the mechanics of the tools being used, and trouble shoot these technologies as unforeseen complications arise. The novel method for AXIOS stent re-deployment described here not only demonstrates this understanding, but also serves as an example of a cost saving recourse for dislodged AXIOS stent re-deployment. Indeed, in an era of cost-conscious care, one must trouble shoot in a manner that is both clinically effective and financially efficient.

Watch the video: http://bit.ly/2O2RYbW.
1687 Argon Plasma Coagulation-Based Removal of Partially-Covered Esophageal Self-Expanding Metal Stent for Anastomotic Leaks Despite Extended Embedment - Challenging Current Standards of Care
Authors: Malik Fahad , Kim Marina , Arya Mukul
Published: October 2019

INTRODUCTION:

Benign esophageal anastomotic leaks can be effectively treated by the placement of esophageal stents. Endoscopic therapy for esophageal anastomotic leaks remains non-standardized. Partially covered self-expanding metal stents (PSEMS) are superior to fully covered stents in the treatment of anastomotic leaks by providing a better seal and therefore promoting quicker healing with shorter time to oral intake. However, the removal of partially covered SEMS is technically challenging due to these stents’ inherent risk of stimulating mucosal hyperplasia and without special technique will lead to esophageal perforation, avulsion or fistula formation during attempted removal. Generally, anastomotic leaks require at least 4 weeks of stent dwelling for clinical success with an average treatment time of 6–8 weeks with recommendations for stent removal by 3 months.

CASE DESCRIPTION/METHODS:

A 69-year-old man with esophageal adenocarcinoma of the distal esophagus status post neoadjuvant chemoradiation followed by Ivor-Lewis esophagectomy with pyloroplasty presented to the hospital with hematemesis and found to have developed two anastomotic leaks within one month of surgery. He was treated with PSEMS measuring 12.5 cm × 20 mm (25 mm at ends). Three months after placement, elective EGD revealed previously placed stent covering the anastamosis with tissue ingrowth at the uncovered ends. Coagulation using argon plasma at 0.8 liters/minute and 55 watts was performed to free the uncovered ends of the stent by destruction of ingrown tissue. The proximal end was freed, however, some tissue remained over the distal end even after extensive attempts at coagulation and debridement. Two days later, the procedure was repeated with continued fulguration to ablate the remaining ingrown tissue at the uncovered ends using argon plasma and a soft over-the-scope cap was used to remove the necrosed tissue. Stent was eventually removed with rat-tooth forceps.

DISCUSSION:

There are many described methods for partially covered esophageal stent removal. We propose a safe and effective method for the removal of partially covered esophageal SEMS with the use of Argon Plasma Coagulation, a soft over-the-scope cap and rat-tooth forceps after an extended stent dwelling time of three months. With this efficient, safe and effective method of stent removal, it is essential that the use of partially covered esophageal SEMS be standard of care in the temporary management of anastomotic leaks.

Watch the video: http://bit.ly/2SooiEC.
1688 Colonoscopic Resection of Appendiceal Endometriosis
Authors: Sharma Bashar , Dawood Enad , Nieto Jose
Published: October 2019

INTRODUCTION:

We present a 66-year-old lady who presented with a polypoid lesion found on screening colonoscopy in the appendiceal orifice. On repeat colonoscopy, a partially inverted appendix was seen. Possible carcinoid was in the differential diagnosis as well as a submucosal lesion.

CASE DESCRIPTION/METHODS:

Using a double channel colonoscopy, the appendicealorifice and the partially inverted appendix were identified. 10 mls of ORISE lifting gel was injected submucosally. Then, using a 2-snare technique. 1 snare was passed over the appendix. The second snare was passed over the distal partially inverted appendix. Then using traction, the appendix was completely inverted into the lumen of the cecum. Afterwards, the snare, which was over the appendix, cut, was closed and standard polypectomy technique was used to cut the appendix. The appendix was then captured with the snare that was used for traction with the other open channel . Clips were deployed to close the defect The gross pathology was sent which revealed an infiltrated appendix with endometrial tissue consistent with appendiceal endometriosis. CT scan follow up did not reveal any evidence of perforation. Patient was discharged within 24 hours from the hospital.

DISCUSSION:

Endometriosis (EM) is the presence of endometrial tissue outside the uterine cavity. Appendiceal EM is rare and comprises about 3% of all gastrointestinal EM with an incidence of less than 1%. It is usually found incidentally during appendectomies or during colonoscopies if the appendicealorifice is found to be inverted. Appendectomies are usually preformed laparoscopically, few cases have been reported of endoscopic resection of an appendix. We are reporting the first case of appendiceal EM that was resected endoscopically.

Watch the video: http://bit.ly/2O2SEhu.
1690 Management of Non-Malignant Enterocutaneous Fistula Using Fully Covered Stent
Authors: Alshati Ali , Muilenburg Diego , Young Yashika , Weissman Simcha , Kachaamy Toufic
Published: October 2019

INTRODUCTION:

Postoperative enterocutaneous fistula (ECF) has a reported prevalence of 3.6% in general surgery, and up to 35% in Crohn disease-related surgery. ECFs can be of low-output, drain < 200 mL/day, or of high-output, drain > 500 mL/day, which unlikely to heal spontaneously. ECFs can cause metabolic disturbances, fluid loss, and malnutrition.

CASE DESCRIPTION/METHODS:

Case 1: A 54-year-old man with a history of colonic transmural necrosis status post multiple surgeries and end transverse colostomy placement, presented with a two-week history of passing stool from the lateral aspect of his peristomal incision, consistent with enterocutaneous fistula. The 2 fistulae ends were seen on the skin, laterally to the stoma (Figure 2c), and both other ends were identified in the stoma lumen. CT fistulogram confirmed the fistulae. After advancing the endoscope into the stoma, a 2 cm friable stenosis was seen (Figure 1a). The fistulae tracts were treated with silver nitrate and were injected with fibrin glue. A 20 mm × 6 cm fully-covered stent was placed (Figure 1b) and sutured in place. A month later the fistulae had healed (Figure 2d), with no recurrence reported. Case 2: A 64-year-old man with a history of metastatic mucinous appendiceal cancer status post multiple abdominal surgeries, referred for his recurrent ECF. CT scan showed air tracking outside the colon at the level of the cutaneous fistula site. Water-soluble contrast pushed through the rectum showed an occlusion with contrast extravasation is seen in the fistula (Figure 3e). Sigmoidoscopy confirmed the site of obstruction and the area of leakage. A fully covered stent was placed to relieve the obstruction and cover the fistula (Figure 3f). Initially, the fistula output resolved, but when the stent was removed a month later, the fistula output returned. So, a stent was placed again and was sutured to the colon. The patient is now asymptomatic and having normal bowel movements.

DISCUSSION:

ECF can cause significant morbidity and affect the quality of life. Surgical repair of ECF has a recurrence rate as high as 36% and is associated with high mortality especially in malnourished patients. Thus, endoscopic intervention using fully-covered stents can be helpful in healing the fistulae. In these 2 cases, the placement of a fully-covered stent relieved the coexisting obstruction, diverted the flow away from the fistula, and simultaneously covered the fistula end. The patients experienced relief of fistula symptoms and avoided them major surgical intervention.

Watch the video: http://bit.ly/30BIvtw.
1691 Lumen-Apposing Metal Stent Assisted ERCP in Stenosis Associated With Silastic Ring in Vertical Banded Gastroplasty
Authors: Gajula Prianka , Dacha Sunil
Published: October 2019

INTRODUCTION:

Lumen-apposing metal stent is being increasingly used for transmural drainage of pancreatic fluid collections (PFC). More recently, certain off label uses for LAMS are being explored1 such as benign gastrointestinal strictures, gastrojejunostomy, and gastro-gastrostomy. Here we present a case of LAMS-assisted ERCP for stenosis in a patient with silastic ring vertical banded gastroplasty.

CASE DESCRIPTION/METHODS:

An 82yo F with h/o breast cancer and diabetes mellitus type 2 was referred for EUS guided biopsy of a pancreatic head mass identified on CT scan of the abdomen, performed during evaluation of abdominal pain. The patient had normal liver enzymes. An EUS was planned for biopsy of pancreatic mass. At the time of the procedure, a benign-appearing, severe, intrinsic stenosis was found in the gastric body. An echoendoscope could not be advanced across this mid-gastric body stenosis, despite balloon dilation to 15mm. No significant mucosal disruption was seen. It was suspected that the stenosis was due to adhesions related to the silastic ring. A 15 mm × 10 mm LAMS was deployed across the stenosis to facilitate EUS. LAMS was dilated to 15 mm with balloon dilation under fluoroscopic guidance. An EUS scope could not be advanced despite dilation of LAMS to 15 mm. A duodenoscope could not be advanced, either. The plan was made to repeat EUS in 48 hrs. However, the patient developed obstructive jaundice, and an ERCP was planned instead. LAMS was removed prior to ERCP due to mild resistance to passage of the scope. This was done to prevent stent dislodgement. Following LAMS removal, a duodenoscope could be advanced across the stenosis with minimal resistance. An ERCP was successfully performed, which revealed a tight distal biliary stricture. Brush cytology was performed using a large caliber brush. A biliary stent was placed. Her immediate post-ERCP course was uncomplicated. She had normalization of her liver function tests. Final cytology results revealed pancreatic adenocarcinoma.

DISCUSSION:

ERCP is a challenging procedure in patients with previous bariatric surgery due to anatomical variations. LAMS have a high success rate for the drainage of PFCs. Many new off-label indications are being identified for LAMS, and the early results are promising1. We present an off-label use for LAMS placement, for facilitating ERCP in patients with stenosis related to silastic ring vertical banded gastroplasty.

Watch the video: http://bit.ly/2LuZ2Mo.
1693 Jejunal Lymphangioma: An Unusual Etiology for Iron Deficiency Anemia
Authors: Shah-Ghassemzadeh Nicole , Jackson Christian
Published: October 2019

INTRODUCTION:

Lymphangiomas are benign tumors characterized by cystic dilation of lymphatic vessels, and can arise from any location throughout the lymphatic system. Small bowel lymphangiomas are rare, and are primarily described in children. When found in adults, these lesions are typically an incidental finding. Pathologic small bowel lymphangiomas are particularly unusual, and have been reported as a rare etiology of massive gastrointestinal bleeding and chronic anemia.

CASE DESCRIPTION/METHODS:

A 65yo African American man with a history of prostate cancer, coronary artery disease, hypertension, hyperlipidemia, and peripheral artery disease was hospitalized for a 6 month history of symptomatic anemia, without signs of overt gastrointestinal blood loss. Vital signs were stable upon presentation, and initial labs were significant for a hemoglobin 8.7, mean corpuscular volume 94, ferritin 28, and iron saturation of 3%. An esophagogastroduodenoscopy was performed which was significant for mild gastropathy, and a colonoscopy that showed mild diverticulosis, a 3 mm polyp and small internal hemorrhoids, without stigmata of recent bleeding. Iron therapy was initiated, and the patient was referred to the outpatient gastroenterology clinic for further workup. The patient next underwent capsule endoscopy which showed a friable small bowel mass, with evidence of active bleeding. A single balloon enteroscopy was then performed, which revealed a 4 cm circumferential, friable, granular mass in the mid-jejunum which was biopsied and tattooed with India Ink. Biopsies of the mass revealed benign small intestinal mucosa with prominent lymphangiectasia. The patient was then referred to surgical oncology and underwent a laparoscopic assisted enteroscopy which again demonstrated the previously seen lesion occupying 75% of the small bowel lumen. The lesion was further evaluated with endomicroscopy which revealed multiple dilated blood vessels and lymphatic channels, in a background of inflammation. The cells appeared organized and without atypical features. A small bowel resection was performed, and the surgical pathology revealed a benign lymphatic malformation involving the mucosa and submucosa consistent with a lymphangioma. No invasive features or malignant cells were identified.

DISCUSSION:

Small bowel lymphangiomas are a rare finding, and primarily found within the duodenum. We report an unusual case of a large jejunal lymphangioma presenting as iron deficiency anemia, which completely resolved after resection of the mass.

Watch the video: http://bit.ly/2LvNhpc.
1698 Endoscopic Placement of Sengstaken-Blakemore Tube
Authors: Rego Rayburn
Published: October 2019

INTRODUCTION:

This video demonstrates the components of the Sengstaken-Blakemore tube, the errors in blind placement of the tube and how the tube can be successfully placed endoscopically, eliminating errors in placement that can turn out to be ineffective, even disastrous.

CASE DESCRIPTION/METHODS:

Please see method described in the video.

DISCUSSION:

Gastroenterologists are wary of this tube and are not familiar with how to use the Blakemore tube. This video demonstrates the components of the tube and how it can be placed endoscopically effectively and without causing harm. Placement of this tube in situations where banding of varices has failed can be life saving and could be a bridge to TIPS procedure.

Watch the video: http://bit.ly/2JGkyfe.
1701 An Aggressive Case of Recurrent Esophageal Stricture in a Patient With Acute Esophageal Necrosis
Authors: Lankarani Daisy S. , Makar Ranjit , Aziz Hamza , Maklad Muthena , Fayad Joseph M.
Published: October 2019

INTRODUCTION:

Esophageal strictures are a known complication of acute esophageal necrosis (AEN). Our patient presented with dysphagia and after EGD was found to have AEN complicated by an esophageal stricture requiring recurrent dilation.

CASE DESCRIPTION/METHODS:

82 y/o male with PMH of HTN and prostate cancer was status post right sided orchiectomy for recurrent orchitis. After surgery, patient disclosed a 2-month history of dysphagia to solids. He reported food “getting stuck” and a 20 lb weight loss in 2 months. EGD showed white exudate in the proximal and mid esophagus that easily sloughed off. The mucosa was ulcerated with underlying granulation tissue (Figure 1). Brushings were negative for candida. Biopsy results from both proximal and distal esophagus showed marked necroinflammatory debris. Patient denied caustic ingestion. Serologic testing was normal. Patient was discharged on a liquid diet, pantoprazole 40 mg PO BID, sucralfate with EGD in 2 months. He returned 1 month later for worsening dysphagia. EGD revealed esophagitis in the mid and distal esophagus and a stricture at 36 cm (Figure 2). The white exudate had improved, but the mucosa was fibrosed. Using a Savary dilator, the stricture was dilated to 7 mm. Over the next 2 weeks, 3 EGD’s with dilation were required for recurrent stricture. On the 4th visit he reported retching and coffee ground emesis for 3 days. EGD revealed an esophageal tear at the stricture site (Figure 3). At the 5th visit, patient was asymptomatic and tolerating a clear liquid diet. EGD showed scarring and fibrosis of the esophageal mucosa and a stricture that was dilated to 12 mm. He will be followed closely due to concern for reformation of the stricture.

DISCUSSION:

AEN has been associated with infections, antibiotics, malignancy, prolonged vomiting etc. It is proposed that a low flow vascular state leaves the esophagus vulnerable to topical injury from acid reflux and pepsin. On EGD, a circumferential black discoloration with underlying friable hemorrhagic tissue is seen with a sharp transition point to normal appearing mucosa at the GE junction. The esophagus may have thick, white exudates that can be dislodged easily to reveal pink granulation tissue. Histology reveals necrosis of the esophageal mucosa and submucosa. Supportive care leads to endoscopic resolution in most patients. Esophageal stricture occurs in 25-40% of patients and requires dilation. Our patient required repetitive dilation as his stricture redeveloped rapidly. He may need PEG for nutritional support.
1704 A Case of Heterotopic Pancreas Discovered in the Distal Esophagus
Authors: Shamoon Dema , Sostre Vanessa , Patel Varun , Volfson Ariy
Published: October 2019

INTRODUCTION:

Heterotopic pancreas (HP) is a congenital abnormality that represents ectopic pancreatic tissue that does not have anatomic, vascular or ductal continuity. The incidence is hard to determine, however, the prevalence of HP is 0.55% to 13.7% on autopsy, 0.2% to 0.5% of abdominal operations, and 0.9% of gastrectomies. HP is most commonly found in the stomach, duodenum, proximal jejunum and rarely, in the esophagus. Approximately 15 cases have been reported in the literature of HP located in the esophagus.

CASE DESCRIPTION/METHODS:

We present a case of a 70-year-old male with a past medical history significant for hypertension, hypercholesterolemia, melanoma, and atrial fibrillation who underwent an esophagogastroduodenoscopy (EGD) for evaluation of heartburn and nausea. Incidentally a 5 mm polypoid appearing lesion in the distal esophagus above the gastroesophageal junction was found. Biopsy results are usually nondiagnostic, however, in our patient, histology revealed squamous mucosa with active esophagitis and associated cardiac-type mucosa with focal pancreatic heterotopia and chronic inflammation in the distal esophagus.

DISCUSSION:

Complications may result from undiagnosed cases of HP including benign or malignant transformation of tissue, pseudocyst formation, pancreatitis, gastrointestinal bleeding, ulceration, gastric outlet obstruction, or intussusception. Treatment depends on the symptom and location. In asymptomatic patients, simple observation may be sufficient, however in patients with symptoms or complications, surgical or Ivor-Lewis Esophagectomy, or laparoscopic resection is recommended. In our case, the patient’s symptoms were treated conservatively with a proton pump inhibitor successfully.
1706 Achalasia With Megaesophagus Presenting as Septic Shock
Authors: Suchartlikitwong Sakolwan , Shroff Roshan , Tikue Alay M. , Mingbunjerdsuk Thammasak , Laoveeravat Passisd , Attaya Mohamed , Islam Sameer , Islam Ebtesam
Published: October 2019

INTRODUCTION:

Achalasia has wide range presentations including gastrointestinal and respiratory symptoms. Septic shock is less common.

CASE DESCRIPTION/METHODS:

We report a case of a 59-year-old Caucasian woman who presented with 1-month history of dyspnea and cough worsening for one week. She reported intermittent vomiting, dysphagia and unintentional weight loss for the past 2 months. Upon admission, she was hypoxemic and developed septic shock. Computer tomography showed multifocal pneumonia and severe distension of the esophagus filled with debris (Figure 1) measuring 9.5 × 6 cm at the largest diameter. She was intubated and given board spectrum antibiotics and then transferred to the medical intensive care unit. Upper endoscopy demonstrated dilation in the entire esophagus filled with food and scattered whitish esophageal plaques, consistent with esophageal candidiasis. Four weeks of oral fluconazole was initiated to treat esophageal candidiasis. Propionibacterium species grew in one out of two blood cultures but the respiratory culture was negative. She required vasopressors for two days and then successfully extubated two days later. She underwent a barium esophagography showing dilated esophagus with distal narrowing “bird beak’s” appearance (Figure 2). Esophageal manometry confirmed type I achalasia demonstrating apersistalsis of the entire esophagus and hypertensive lower esophageal sphincter (Figure 3). She recovered from aspiration pneumonia and weaned off oxygen. She was scheduled to come back in 2 weeks for perioral endoscopic myotomy evaluation and was discharged home with oral fluconazole.

DISCUSSION:

Achalasia is an esophageal disease caused by loss of relaxation in the distal esophagus and lower esophageal sphincter. Most common presentations are dysphagia (90%), heartburn (75%) and regurgitation or vomiting (45%). Respiratory symptoms including cough or chronic aspiration account for 20-40%. However, septic shock as initial presentation is not common. Our patient had chronic aspiration to the lungs and developed aspiration pneumonia progressing to septic shock. Patients presenting with respiratory symptoms are reported to have a more dilated esophagus with an average mean diameter of 4.3 ± 2 cm. Our case has an esophagus double the average size. Perioral endoscopic myotomy has gained universal acceptance to treat achalasia and shows safety and efficacy.
1709 A Rare Case of Muscular Dystrophy in an Adult Diagnosed by Suspicion on High Resolution Esophageal Manometry
Authors: Jarvis Mackenzie , Thompson Eric , Moshiree Baha
Published: October 2019

INTRODUCTION:

Oropharyngeal dysphagia with severe upper esophageal sphincter (UES) dysfunction may be seen due to neuromuscular, neurodegenerative and structural diseases. However, the diagnosis of Myotonic Dystrophy based on interpretation of High Resolution Esophageal Manometry (HRM) is rare.

CASE DESCRIPTION/METHODS:

A 28-year-old Caucasian man presented with a history of dysphagia since childhood with choking and gasping during sleep. During meals he regurgitated frequently and drank large amounts of water to swallow food. He had dysphagia to both solids and liquids. Patient also noted coughs after most meals. He noted a weight loss of 25 pounds with a normal appetite. Patient wanted to eat but was worried about choking. No prior history of food allergies, asthma or food intolerances. No seasonal allergies. Past medical history notable for a normal upper endoscopy. On physical examination the patient was noted to have an elongated face with drooping of his eyelids bilaterally. He had thinning of his temporal area, jaw and anterior neck musculature and thenar wasting bilaterally. Weakness of both extremities was noted with normal reflexes. Review of prior testing was done. A Modified Barium Swallow study showed no evidence of aspiration or penetration and decreased hyolaryngeal excursion with impaired epiglottic inversion with decreased duration of the cricopharyngeal. Given the conflicting findings above, a HRM was performed in our motility lab. (See Figures 1 and 2). Solid swallows were unable to be performed due to the severe extent of the patient’s dysphagia and risk of aspiration. Based on our manometry results, we performed the following testing to rule out neuromuscular diseases prior to his referral to a neurologist. Several serologic testing was performed. (see Table 1) Based on testing, he had an elevated Aldolase and CPK with suspicion of a muscular disorder. For his absent contractility based on his HRM, he was started on Bethanechol, a cholinesterase inhibitor and muscarinic agonist at a dose of 25 mg prior to meals. Patient’s nutrition was supported with protein supplementation and a Gastrostomy-Jejunostomy tube was suggested due to significant oropharyngeal dysphagia. He was referred to the Myotonic Dystrophy Clinic.

DISCUSSION:

Patient’s presenting with oropharyngeal dysphagia who are found to have a hypotensive UES on HRM should spark concern for a myopathy or neurological etiology.
1715 Esophageal Stent Causing Osteomyelitis: An Emerging Complication
Authors: Stone Bryan , Odah Tarek , Shafa Shervin
Published: October 2019

INTRODUCTION:

Esophageal stents are used to treat a wide variety of problems, most commonly malignant dysphagia as a form of palliation. Delayed complications include tumor ingrowth/overgrowth, stent migration, hemorrhage, and delayed perforation. We present a rare case of osteomyelitis secondary to a stent that was placed for the closure of a tracheoesophageal fistula.

CASE DESCRIPTION/METHODS:

A 55-year-old female presented with stage IV non-small-cell lung cancer with distant metastases. She was started on chemotherapy (gemcitabine and carboplatin) as well as immunotherapy (pembrolizumab). A bronchoscopy had revealed extensive cancer in the bronchial tree and detected a tracheoesophageal fistula, which required placement of an esophageal stent for closure. The stent had been repositioned twice for better location and patient comfort. Four months after the last stent, she presented with fevers, which was initially attributed to her malignancy. However, her symptoms eventually progressed to dysphagia, cough, chest and back pain. Serologic evaluation was notable for an elevated ESR at 112 and an elevated CRP of 105. Subsequent CT of the chest revealed erosive endplate changes at the T1-T2 vertebral level with soft tissue density adjacent to the proximal aspect of the stent. These findings were concerning for osteomyelitis in the setting of an esophageal stent erosion. The decision was made to reposition the stent endoscopically. EGD revealed that the proximal end of the stent was embedded into the esophageal wall without clear erosions or evidence of perforation. Attempt to reposition the esophageal stent was performed, but follow up CT revealed minimal change from endoscopic repositioning. No further endoscopic intervention was performed and she was treated for osteomyelitis with intravenous antibiotics.

DISCUSSION:

Few cases have reported osteomyelitis related to esophageal stent migration. Whether the stent-related osteomyelitis is potentiated by the effects of chemotherapy on the esophageal wall or related to pressure erosion caused by the stent is not entirely clear. With newer therapies for malignancies and increased life expectancies, new complications may emerge. The decision to perform endoscopic manipulation would largely depend on patients’ clinical status and a discussion of risks versus benefits in a case-based scenario. This case illustrates the importance of having a high index of clinical suspicion for osteomyelitis in a patient with previous esophageal intervention.
1718 Acute Esophageal Necrosis in Patient With Decompensated Cirrhosis
Authors: Tosounian Shannon L. , Miick Ronald , Walter James
Published: October 2019

INTRODUCTION:

Acute Esophageal Necrosis (AEN) is a rare condition characterized by diffuse circumferential necrosis of esophagus. The majority of cases have no identified etiology, but risk factors that may lead to hypoperfusion (thromboembolic events, sepsis, trauma, vasculopathy) are typically present. We present the case of a woman with decompensated cirrhosis presenting with hematemesis and endoscopic findings of AEN.

CASE DESCRIPTION/METHODS:

A 66-year-old female with cirrhosis secondary to alcohol abuse complicated by ascites presented from home due to witnessed hematemesis. History was limited due to patient’s mental status. Upon initial examination her blood pressure was 128/53 mmHg, heart rate of 118 bpm, Sp02 of 84%. On examination she appeared lethargic and in mild distress with dried blood in her oropharynx. Her abdomen was soft but distended. Laboratory results included: WBC 24.0 103/mcL, Hemoglobin 4.9 g/dL, Platelets 234 103/mcL, INR 2.7, and lactic acid 4.18 mmol/L. A chest X-ray showed bilateral pleural effusions. She was started on pantoprazole and octreotide drips, ceftriaxone, and two units of packed red blood cells. She was taken emergently for upper endoscopy due to concerns for variceal hemorrhage. The entire lumen of the esophagus extending from the incisors to top of gastric folds was black and necrotic-appearing circumferentially (Figures 1 and 2). Biopsies were obtained (Figure 3). Type 2 gastroesophageal varices, medium in diameter with no bleeding were found in the gastric fundus. She was placed on broad spectrum antibiotics and admitted to medical ICU. The following day she had increased O2 requirements secondary to acute respiratory distress syndrome and required intubation. She became hemodynamically unstable requiring vasopressors, then developed an acute kidney injury requiring continuous renal replacement therapy. Due to declining clinical status, she was made comfort care and ultimately expired on Day 4 of admission. Esophageal pathology demonstrated necrotic esophageal mucosa with acute and chronic inflammation. The etiology of her necrotic esophagus remains unclear.

DISCUSSION:

AEN is a rare diagnosis associated with low perfusion state with an estimated 32% mortality rate. It is associated with liver dysfunction in approximately 15% of cases, as in our patient. Early recognition and supportive care is crucial for survival, and further studies are needed to better understand etiology and management of AEN.
1722 Dysphagia Lusoria Associated With Imperforate Anus
Authors: Andersen Karl , Hoff Ryan T. , Silas Dean N.
Published: October 2019

INTRODUCTION:

Dysphagia lusoria is a rare intrathoracic vascular abnormality that results in the compression of the esophagus, causing dysphagia. The most common cause of dysphagia lusoria is an aberrant right subclavian artery of the aortic arch, though nearly all major arteries within the thorax have been reported to cause cause this condition.

CASE DESCRIPTION/METHODS:

68-year-old male with a history of developmental delay and imperforate anus s/p colostomy and colostomy revision presented with decreased appetite, decreased ostomy output, and regurgitation of food and water. Past medical history was notable for GERD and prior small bowel obstructions. Abdominal obstructive x-ray series showed multiple nondilated gas-filled loops of small bowel. Chest x-ray showed tortuosity of the thoracic aorta. Fluoroscopic swallow evaluation showed no evidence of aspiration, and barium esophagram showed the calcified aortic arch trapping the proximal esophagus anteriorly and posteriorly, resulting in a narrowed channel with a normal appearing distal esophagus (Figure 1). CTA chest confirmed compression of the esophagus by the anomalous aortic arch (Figure 2). Multiple treatment options were considered. However, due to the patient's poor performance status and ability to tolerate small frequent sips of liquids, no surgery was pursued. The patient was discharged home in satisfactory condition.

DISCUSSION:

The majority of patients with dysphagia lusoria are asymptomatic and the discovery of the anomaly is often incidental. This patient had a tortuous thoracic aorta, which was known from previous imaging studies, but remained without dysphagia until this admission. The median onset of symptoms is 48-50 years; the late-onset of this condition may be due to the increased rigidity of the esophagus or calcification and atherosclerosis of the major vessels, decreasing their compliance. The presenting symptoms of dysphagia lusoria is usually progressive dysphagia, usually for solids, accompanied by regurgitation of unchewed foods, chest pain, or cough. The diagnosis is usually achieved with an initial barium esophagram, followed by CT or MRI scan. Endoscopic ultrasound with doppler is also used for diagnosis. Surgery is the preferred treatment option for symptomatic patients that can tolerate it. To our knowledge, this is the first reported case of dysphagia lusoria associated with development delay and isolated imperforate anus.
1733 Wonder Neutralization: Esophageal Stents in Caustic Injury
Authors: Leon-Jarrin Daniela , Kumar Manoj , Fahmawi Yazan , Mizrahi Meir
Published: October 2019

INTRODUCTION:

Introduction Common causes for benign esophageal strictures (ES) are post -surgery, caustic ingestions and radiation therapy. Caustic strictures of the gastrointestinal tract can be a challenge to treat even after multiple endoscopic treatments due to its inherent relapsing nature. We report here our experience with self-expandable metallic stents (SEMS) in a patient with corrosive stricture of the esophagus.

CASE DESCRIPTION/METHODS:

Case A 25-year-old female with 2-year history of refractory ES due to caustic injury presented for endoscopic treatment. Patient had multiple endoscopic dilation attempts in past. Pediatric gastroscope showed esophageal stricture starting at 20 cm from the incisors however it could not traverse through the stricture. Under fluoroscopic guidance a 0.035 in x 260 cm guidewire was placed in the stomach. The proximal end of stricture was occluded by biliary 8.5 mm stone extraction balloon and contrast was injected through balloon catheter under fluoroscopy guidance showing 12 cm long significantly narrowed ES. A 18 mm × 103 mm fully covered esophageal metal stent (FCEMS) was placed under fluoroscopic guidance keeping the distal end of the stent above the gastroesophageal junction. Four days later, follow up EGD showed previously placed FCEMS was patent and widely open. The distal end of the stent was at 27cm and GEJ was at 35cm from entry point. Under fluoroscopic imaging and wire guidance another FCEMS (18 mm × 153 mm) was placed successfully to treat the left-over portion of the stricture below the previously placed stent. The second stent was deployed with in the first stent with its distal end at GEJ. Post stent placement, endoscopic and fluoroscopic imaging’s were satisfactory. At 2 weeks follow up, patient revealed significant improvement in her symptoms and ability to tolerate soft diet.

DISCUSSION:

Discussion ES secondary to caustic injury tend to require multiple dilation procedures, multiple hospitalizations with associated risks and cost, affecting patient’s quality of life. There is a need for novel therapeutic strategies that will provide a long-term solution. Our case highlights the growing interest and utility of multiple FCEMS in the treatment of severe and long ES. The deployment of multiple FCEMSs in our patient with long history of ES related dysphagia dramatically improved her symptoms and patency of esophagus.
1734 An “Off the Wall” Case of Sloughing Esophagitis
Authors: Johnson Alyson M. , Koutlas Nicholas J. , Guy Cynthia D. , Wilson Joanne A.
Published: October 2019

INTRODUCTION:

Esophagitis dissecans superficialis (EDS), or sloughing esophagitis, is a rare, benign disease characterized by large, longitudinal sheets of sloughing mucosa visualized on upper endoscopy. Symptoms typically vary and include dysphagia, odynophagia, abdominal pain, and dyspepsia. EDS has been associated with medications, chemical and thermal irritants, autoimmune bullous dermatoses, and celiac disease. However, its pathogenesis is still poorly understood. We present a case of EDS in a patient with multiple comorbid autoimmune disorders including type 1 diabetes mellitus, Hashimoto’s thyroiditis, and celiac disease.

CASE DESCRIPTION/METHODS:

A 22 year old female was admitted with diabetic ketoacidosis (DKA), dysphagia, abdominal discomfort and weight loss. Her medical history included poorly controlled type 1 diabetes mellitus, celiac disease, and Hashimoto’s thyroiditis. Her upper gastrointestinal symptoms led to anorexia and unintentional weight loss. After resolution of DKA, Gastroenterology was consulted for evaluation of her symptoms. Upper endoscopy was performed which revealed mild esophagitis, mild gastritis, and scalloping in the duodenum. Esophageal biopsies demonstrated fragments of squamous mucosa with features consistent with "sloughing esophagitis". Her appetite eventually improved with initiation of proton pump inhibitor therapy and management of her poorly controlled diabetes. On outpatient follow up, her upper GI symptoms continued to improve and her weight stabilized.

DISCUSSION:

EDS is a rare endoscopic finding of white plaques in vertical columns that represent sloughing of large fragments of squamous tissue. Histologically, the most common features of EDS are parakeratosis, pauci-immune intraepithelial sloughing, and intraepithelial splitting. The pathogenesis of EDS is not fully understood though has been associated with autoimmune skin disorders and celiac disease. There are no specific treatments for EDS as it is usually self-limited. We present a case of sloughing esophagitis in a patient with multiple pre-existing autoimmune diseases including type 1 diabetes mellitus, Hashimoto’s thyroiditis, and celiac disease. This case is unique in that she has a polyglandular like autoimmune disorder. This suggests that autoimmunity may play a role in the pathogenesis of EDS. Interestingly, she lacked all of the dermatologic manifestations that are most frequently associated with EDS.