bluuebunny/crossref_metadata_2025 huggingface dataset:
2151 Size Matters: A Case of Recurrent Proximal Esophageal Stenosis Treated With a Biliary Self Expanding Metal Stent (SEMS)
Authors: Viswanathan Sahityan , Dobin Timothy , Hoang Long
Published: October 2019

INTRODUCTION:

Esophageal stenosis after radiotherapy occurs in up to 15% of patients within 3 months of treatment. Endoscopic dilation remains the standard of care for cervical esophageal stenosis with refractory cases requiring stenting. Proximal stenosis pose a challenge as standard esophageal stents can cause cervicalgia and globus sensation due to their size and expansive force making the a biliary SEMS a better solution.

CASE DESCRIPTION/METHODS:

Patient is a 72 year-old Vietnamese male with pertinent past medical history of stage IV laryngeal cancer status post total laryngectomy, radiotherapy, and tracheostomy presenting with recurrent dysphagia. Patient had previously undergone four endoscopic dilations within the previous month for the same complaint. Upper endoscopy at time of admission revealed a recurrent benign stricture at the level of the upper esophageal sphincter. Given previous failed dilations, severity of stricture, and patient’s refusal for surgical correction or a gastrostomy tube, a biliary SEMS was placed with palliative intent. A fully covered biliary SEMS measuring 10 mm × 60 mm was deployed at the level of the stricture resulting in symptom resolution for 5 months. On recurrence of dysphagia, evaluation revealed distal migration of the SEMS. Retrieval was unsuccessful and the existing SEMS was overlapped with another 10 mm × 60 mm biliary SEMS which resulted in a symptom-free interval of 11 months. Both SEMS were retrieved and exchanged for a fully covered esophageal SEMS (18 mm). Patient had persistent symptoms and endoscopy revealed proximal migration of the esophageal SEMS. The esophageal SEMS was retrieved and a biliary SEMS (10 mm) was again deployed at the level of the stricture which resulted in resolution of symptoms. Patient has since had the stent exchanged every 3-4 months due to stent migration.

DISCUSSION:

Recurrent proximal esophageal stenosis pose a challenge for endoscopists due to their challenging anatomy. Standard esophageal stents currently available in the market start at a diameter of 12 mm making it less ideal for proximal esophageal strictures that cannot tolerate the expansive force of the larger stents. We have demonstrated the success of using a smaller-diameter biliary stent for the relief of dysphagia along with longer symptom-free intervals when compared to dilation and standard esophageal stents. This case demonstrates the need for further research and development of specialized esophageal stents for the treatment of recurrent proximal esophageal stenosis.
2153 Migrated Biliary Stent: When Everything Fails
Authors: Vecchio Eric , Wungjiranirun Manida , Simmons Shannon , Habr Fadlallah
Published: October 2019

INTRODUCTION:

Migrating stents are a well-known complication of biliary stenting, occurring in 5-7% of patients undergoing ERCP. Numerous endoscopic devices are used to remove stents. However, we describe removal of a proximally migrated biliary stent using a cholangioscopy-guided retrieval basket.

CASE DESCRIPTION/METHODS:

An 86-year-old woman was admitted for septic shock, E. coli bacteremia and cholangitis. Urgent ERCP demonstrated two diverticuli with the major papilla inside one of them. Cholangiogram revealed CBD dilation to 8 mm with few small and large choledocholithiasis. A sphincterotomy and endoscopic dilation of the papilla were performed. However, due to duodenal spasms compromising visualization of the papilla and the associated sepsis, a 10-French by 9 cm plastic stent was placed in the biliary tree and the procedure was aborted. Repeat ERCP four weeks later showed the stent had migrated into the bile duct and was embedded behind the neck of the periampullary diverticulum. Multiple attempts to remove the stent using balloons, baskets, snares and Rat tooth forceps were unsuccessful. A repeat ERCP two weeks later showed the stent still embedded in the bile duct. A Spyglass cholangioscope was introduced into the bile duct and the retrieval basket was used to grasp the distal flap of the stent. Next, both the cholangioscope and stent were successfully withdrawn from the CBD. Finally, the bile duct was swept and remaining stones were removed. Re-inspection of the bile duct with the cholangioscope demonstrated no residual stones or biliary injury.

DISCUSSION:

Biliary stent migration is a relatively uncommon complication of ERCP. Multiple endoscopic tools have been described to retrieve migrated stents. These include retrieval balloons, baskets, and forceps. The newly developed Spyglass retrieval basket allows direct visualization and removal of the targeted object whether it is a stone or stent. This technique is a nice addition to our armamentarium for clearing the biliary tree. It could potentially lead to decreased radiation exposure and probably to a decrease in the number of procedures. The use of this device to remove migrated stents has not been previously reported. The main difficulty in our case was the suboptimal visualization once the basket was tightened around the stent as this blocks the view of the cholangioscope. Further advances are needed in order to develop devices that are able to close further away from the scope camera preserving cholangioscopic view of the biliary lumen.
2159 Endoscopic Management of Isolated Gastric Varices: Hematemesis in Pancreatitis-Induced Splenic Vein Thrombosis
Authors: Peng Frederick B. , Kligman Eugene , Chan Johanna L.
Published: October 2019

INTRODUCTION:

Brisk upper GI bleeding with acute blood loss anemia requires emergent endoscopic evaluation. Often, lesions are due to peptic ulcer disease or variceal hemorrhage. Here, we present a case of isolated bleeding gastric varices in a patient with splenic vein thrombosis likely due to recurrent episodes of acute pancreatitis.

CASE DESCRIPTION/METHODS:

A 48-year-old man with alcohol abuse, thrombocytopenia, and chronic LUQ abdominal pain presented with four days of hematemesis and melena. He intermittently takes PPI, but reported no NSAID use or history of H. pylori. Previously, two similar episodes associated with severe epigastric pain radiating to his back occurred with heavy drinking. On exam, he is hemodynamically stable with an unremarkable abdominal exam. His admission hemoglobin is 4.9 g/dl and BUN is 26 mg/dl. He is resuscitated with blood products and EGD reveals type 1 isolated gastric varices (IGV) in the fundus with stigmata of recent bleed (Figure 1). Subsequent EUS confirms presence of fundal varices. Hemostasis is achieved with coiling and cyanoacrylate (CYA) glue (Figures 2 and 3). CT A/P shows splenomegaly with chronic splenic vein thrombosis with collateral gastric varices. On discharge, he is counseled on alcohol cessation, as his bleeding gastric varices were attributable to pancreatitis-induced splenic vein thrombosis (PISVT).

DISCUSSION:

PISVT is a sequalae of acute and chronic pancreatitis. The pathophysiology is centered on left-sided portal hypertension with collateral blood flow developing in the splenoportal or gastroepiploic systems. Most patients with subsequent IGV are asymptomatic, but in high-risk symptomatic groups, EUS guided CYA glue injection and intravascular coil embolization is an emerging therapy that has the potential to achieve higher rates of hemostasis and lower rebleeding rates compared to sclerotherapy or balloon-occluded retrograde transvenous obliteration. A recent study demonstrated that out of 100 patients who underwent EUS-guided coil and CYA glue injection, 93 had complete obliteration (on Doppler study) of gastric fundal varices on follow-up EUS examination (Bhat, GIE 2016). Patients who do not achieve hemostasis after CYA injection and coil should be considered for splenic artery embolization or splenectomy, which is currently the gold standard for management of splenic vein thrombosis complicated by variceal hemorrhage. A large comparison trial would be most beneficial to validate this treatment modality compared to existing conventional therapies.
2161 A Rare Case of Pancreatic Lymphoepithelial Cyst
Authors: Kim Grace E. , Ramay Fariha , Richards Stephanie , Darwin Peter
Published: October 2019

INTRODUCTION:

Pancreatic lymphoepithelial cyst (LEC) is a rare, benign collection of keratinizing squamous epithelial cells encapsulated by lymphoid tissue. Because of its limited data and nonspecific features that can mimic malignant lesions, LECs can lead to unnecessary operations. Here we describe a rare case of pancreatic LEC.

CASE DESCRIPTION/METHODS:

A 62-year-old male with a known pancreatic mass presented with abdominal pain. CT scan showed a 36 × 52 mm mass in the pancreatic head with no pancreatic ductal dilation or retroperitoneal lymphadenopathy (Figure 1), which increased in size compared to previous imaging. Endoscopic ultrasound (EUS) showed a well-defined, avascular 49 × 29 mm heterogenous hypoechoic mass by the pancreatic neck without pancreatic ductal dilation (Figure 2). Subsequent EUS-guided fine needle aspiration (FNA) revealed rare fragments of benign-appearing squamous epithelium in a background of keratin debris, cyst contents, and scattered lymphocytes, consistent with a lymphoepithelial cyst (Figure 3).

DISCUSSION:

Pancreatic LEC is an extremely rare lesion that comprises of only 0.5% of all pancreatic cysts. It occurs in males 50-60 years of age as an incidental finding, albeit patients may present with abdominal pain and nausea. A majority of the LECs are round, anechoic or hypoechoic, exophytic complex cystic lesions with enhancing septa or rim. However, these features can overlap with other pancreatic lesions such as intraductal papillary mucosal neoplasms that have malignant potential, leading to unnecessary surgical intervention. Thus EUS-FNA has become the mainstay for diagnosing pancreatic LECs, which show an outer layer of lymphoid tissue and an inner layer of mature squamous epithelium without atypia. Given the slow growing and benign nature, conservative management and observation is adequate for pancreatic LECs with excellent long-term outcome. With increasing number of imaging ordered by clinicians, it is anticipated that there will be a greater number of incidental pancreatic LECs detected, which in turn can increase the number of unnecessary procedures. EUS-FNA should be utilized more frequently to help distinguish benign pancreatic LECs from premalignant or malignant lesions to avoid surgery. It is important for clinicians to become more familiar with the cytopathological characteristics of pancreatic LECs, and this case highlights the importance of EUS-FNA in accurately diagnosing a rare pancreatic LEC.
2168 Type II Choledochal Cyst With Obstructive Jaundice and Chronic Pancreatitis: A Case Report
Authors: Nallapeta Naren S. , Jamil Sohaib , Rivera Ramon
Published: October 2019

INTRODUCTION:

Choledochal cysts are a rare congenital cystic dilation of the biliary tract and occur commonly in female infants and young children. Although rare in Western countries, choledochal cysts are more common in East Asian countries with Type II cysts accounting for only 2% of reported cases. We present an interesting case of a Type II choledochal cyst in a patient with chronic pancreatitis.

CASE DESCRIPTION/METHODS:

A 56 year old male presented with abdominal pain associated with nausea and non-bloody emesis. He also had reduced appetite, dark urine, and a 10 pound weight loss over several months. Physical examination revealed scleral icterus and epigastric abdominal tenderness. Laboratory investigations revealed mild leukocytosis (11.1), elevated total bilirubin (8.6), aspartate aminotransferase (77), alanine aminotransferase (128), and alkaline phosphatase (556). A CT with intravenous contrast (Figure 1) demonstrated coarse calcifications within the pancreas, a large cystic lesion within the head of the pancreas with marked pancreatic ductal dilation, atrophy, and intraductal calcifications. Gallbladder distension with sludge and upstream biliary dilatation was also noted. Endosonographic images (Figure 2) revealed an anechoic cystic lesion in the head of the pancreas with compression of the common bile duct (CBD). Fine needle aspiration was performed with aspirated fluid highly suggestive of bile. A cholangiogram confirmed the presence of an intrapancreatic cystic cavity in direct communication with the distal CBD in a diverticular configuration suggestive of a Type II choledochal cyst with narrowing of the adjacent CBD. A pancreatic sphincterotomy followed by pancreas stone lithotripsy and stone extraction was performed. A biliary stent was placed into the CBD. The patient tolerated the procedure well and was scheduled for multidisciplinary discussion pending brush cytology.

DISCUSSION:

Choledochal cysts are congenital anomalies which results in cystic dilation of the biliary tree. Adults are more likely to present with biliary or pancreatic symptoms whereas children present with an abdominal mass and jaundice. Malignancy is associated with Type I and IV cysts while Types II, III, and V cysts have minimal neoplastic risk. Treatment is based on the cyst type. Diverticulectomy of Type II choledochal cyst followed by primary CBD closure at the diverticulum neck is usually sufficient. A multidisciplinary approach may be warranted based on patient clinical status and co-morbidities.
2170 Endoscopic Management of Gastric Outlet Obstruction Due to a Large Gallstone ("Bouveret's Syndrome")
Authors: Ali Saad Emhmed , Benrajab Karim , Tripathi Nishant , Gabr Moamen , Mardini Houssam , Frandah Wesam
Published: October 2019

INTRODUCTION:

Bouveret's syndrome is referred to a gastric outlet obstruction due to an impacted gallstone in the duodenum following cholecystoduodenal fistula. Surgery is required in certain cases, but the mortality rate is up to 30 %. Endoscopic management has been reported with a low success rate. We demonstrate a successful endoscopic mechanical and electrohydraulic lithotripsy of a large gallstone causing gastric outlet obstruction.

CASE DESCRIPTION/METHODS:

A 88 years old female presented with a three-day history of right upper quadrant abdominal pain (RUQ), nausea, and non-bilious vomiting. Past medical history is significant for hypertension, coronary artery disease, and type 2 diabetes. Vital signs were normal. Pertinent findings included tenderness to palpation in the epigastric and RUQ regions, normal bowel sounds, and a loud succession splash. Labs revealed Hgb 10.2 g/dl, WBC 7k/mm3, platelets 289k/mm3, BUN 13 mg/dl, creatinine 0.6 mg/dl. Plain abdominal X-ray showed round calcified structure in the right mid abdomen (Figure 1). CT scan of the abdomen showed 4 cm × 3.5 cm gallstone causing complete obstruction of the duodenum, cholecystoduodenal fistula, pneumoperitoneum, and distended stomach (Figure 2). Upper endoscopy revealed a large gallstone impacted in the first part of the duodenum, extensive ulceration of the duodenal wall with a small perforation at the site of stone impaction (Figure 3). Mechanical and electrohydraulic lithotripsy was performed, and the stone was fragmented into small pieces in the duodenum. There was spontaneously sealed duodenal perforation with fat and omental plug. The endoscopic lithotripsy was performed without difficulty. The patient was improved, tolerated an oral diet, and discharged home in a stable condition.

DISCUSSION:

Bouveret’s syndrome is a rare cause of gastric outlet obstruction and characterized by impaction of a gallstone within the pylorus or duodenum. It occurs mostly in elderly, female patients with an average age of 70 years. Given that most patients are elderly with multiple comorbidities, they are poor surgical candidates. The endoscopic approach is considering to be a good alternative. As we demonstrated in our case, these patients can be successfully managed endoscopically with lithotripsy despite the low success rate that was reported in the literature. Endoscopic treatment is effective and safer and should be considered as a first line option.
2171 EUS-Guided Transrectal Drainage and Stent Placement for Large Presacral Abscess Secondary to Acute Appendicitis
Authors: Ali Saad Emhmed , Elghezewi Adnan , Gabr Moamen , Mardini Houssam , Frandah Wesam
Published: October 2019

INTRODUCTION:

A presacral abscess is one of the most difficult abscesses to be drained. It is very challenging to drain it through the transabdominal route due to overlying pelvic structures. We present a patient with sizeable presacral abscess secondary to acute appendicitis that was drained transrectal under an endoscopic-ultrasound (EUS) guidance with stent placement.

CASE DESCRIPTION/METHODS:

A 23-year old male presented with worsening pelvic pain, fever, and chills for four weeks. He denies any change in the bowel movement, dysuria, recent trauma, or bladder or bowel incontinence. Past medical history was unremarkable and had no surgeries. Vital signs were normal except for the temperature of 101.2 F. Abdomen was soft, non-tender, with audible bowel sound. The rectal and genital exam was normal. Labs revealed Hgb 11.2 g/dl, WBC 17.9k/mm3, platelets 545k/mm3, creatinine 0.7 mg/dl, CRP 18.8 mg/dl, negative HIV, and negative urine and blood cultures. CT scan of the abdomen and pelvis revealed large presacral abscess and possibly ruptured acute appendicitis. Magnetic resonance enterography (MRE) showed 9.6 × 2.6 × 6.1 cm presacral abscess with acute ruptured appendicitis (Figure 1). Interventional Radiologist was consulted for drainage, but abscess was not amenable to be drained percutaneously. Despite being on intravenous antibiotics, the patient continued to be spiking febrile and having persistent pelvic pain. So, rectal endoscopic ultrasound (EUS) was performed and showed 5 cm × 3.5 cm abscess in the pre-rectal space (Figure 2). Aspiration was done with the 19-gauge needle using a transrectal approach. A 7Fr x 5 cm double pigtail plastic stent and a 10Fr x 5 cm double pigtail plastic stent were placed into the abscess (Figure 3). Good drainage from the stent was visualized into the rectum. Patient’s symptoms improved. Fluid cultures remained negative, Leukocytosis resolved, and he was discharged in a stable condition. He will follow up with a repeated CT pelvis in 2 weeks to assess for resolution of abscess and interval appendectomy.

DISCUSSION:

The presacral abscess is a complication with difficult management in the course of acute appendicitis. It is challenging to drain with the transabdominal route because of the overlying pelvic structures. EUS-guided transrectal drainage is safer and effective in these cases. The clinician should be aware of this treatment modality and considered as the first-line option.
2172 Importance of Chest and Abdominal Imaging Before Placing a PEG Tube
Authors: Chaudhury Samiran Roy , Oak Rachana , Kumar Kavita , Bernstein Michael
Published: October 2019

INTRODUCTION:

Percutaneous Endoscopic Gastrostomy (PEG) tube placements are a common procedure these days and are often seen as a safer and cheaper alternative to surgical gastrostomy tube placement with increasing rate of deployment over the years. They are however dependent on several factors including anatomic presentation and availability of resources.

CASE DESCRIPTION/METHODS:

A 75 year old lady with multiple medical conditions who came to hospital from nursing home after she was noted to have failure to thrive and dysphagia. After admission GI was consulted for PEG placement. Initial physical exam during the consult revealed benign abdomen – non tender, non-distended with present bowel sounds without deformities. On imaging however, the chest x-ray (Figure 1) shows the presence of the patient’s stomach and small bowel within the patient’s chest cavity due to a large hiatal hernia, as well as pleural effusion with left lower lobe infiltrate. CT chest (Figures 2 and 3) was done to confirm CXR findings and revealed a large retro-cardiac hernia containing multiple loops of large bowel, small bowl and stomach with segmental left lung subluxation. Patient was treated with antibiotics for aspiration pneumonia; however, patient was deemed to be a poor candidate for PEG placement due to anatomy as well as a poor candidate for hernia repair given advanced age and comorbid medical conditions. Given poor prognosis, goals of care were discussed with patient’s family who opted for a palliative approach and patient was eventually discharged to a hospice care facility.

DISCUSSION:

While PEG placement is becoming a rapidly prevalent procedure, there is no guideline regarding risk stratification of placement with use of imaging. In our experience, imaging should be a main stay of initial investigation alongside history and physical exam given that anatomic variations/changes may not always be apparent on history and physical exam alone.
2173 Successful Endoscopic Drainage of Intraperitoneal Hematoma Using Lumen Opposing Fully Covered Metal Stent and Intracavitatory Thrombolytics
Authors: Olivier Sarah , Gollapudi Lakshmi Asritha , Tewari Virendra
Published: October 2019

INTRODUCTION:

Incompletely drained intraperitoneal collections represent a therapeutic challenge. Interventional radiologists and surgeons have employed adjunctive intracavitary fibrinolytic agents to break down collections, however it has not been employed endoscopically to the best of our knowledge. We present a case of an intraperitoneal hematoma in a patient which was successfully drained endoscopically using thrombolytics.

CASE DESCRIPTION/METHODS:

A 16 year old male with past medical history of idiopathic thrombocytopenic purpura presented to our hospital with complains of left upper quadrant abdominal pain, radiating to the back for four days prior to the presentation. He also reported a blunt trauma to the upper abdomen two months prior to the presentation. Abdominal examination revealed tenderness to palpation in LUQ, with no guarding or rigidity and normal bowel sounds. Laboratory values at the time of presentation were within normal limits. Upper endoscopy and Colonoscopy were performed. Upper endoscopy revealed mild erosive gastritis. Colonoscopy was normal. He underwent Computed Tomography (CT) of abdomen and pelvis with contrast, revealing a 5 × 6 × 6.7 cm mass likely a hematoma abutting the spleen, pancreas and left kidneys. Hospital course complicated by fever and leukocytosis. Transgastric drainage of hematoma was performed by Endoscopic Ultrasound (EUS) using fully covered lumen opposing 1.5 cm wide and 1 cm long stent placement with initial drainage of purulent material. Two additional EGDs needed over subsequent two weeks to address one episode of fever with unchanged collection size and thick internal debris. First washout was done with 2000cc of Normal Saline, 500cc of Gentamicin, and 4 mg of Alteplase. During the second washout, we instilled 4 mg of Alteplase and 5 mg DNAse in 60 ml saline with occlusion technique for 10 minutes and subsequent drainage. Patient was discharged and was symptom free. CT scan performed at 8 weeks post placement showed complete drainage of hematoma and stent was removed. Patient is pain free and doing well after that.

DISCUSSION:

The use of fibrinolytics in endoscopic drainage of intraabdominal effusions has not been explored. In our case the use of fibrinolytics facilitated the dissolution of thick internal debris resulting in complete resolution of the collection. In conclusion, adjunctive use of tPA and DNAse along with EUS guided drainage appears to be safe and effective to dissolve thick internal debris avoiding the need for surgical intervention.
2176 An Old Friend in a New Neighborhood: The Presentation and Management of Intraductal Hepatocellular Carcinoma
Authors: Beard Jasna I. , Philips George
Published: October 2019

INTRODUCTION:

Hepatocellular carcinoma (HCC) remains one of the most commonly addressed issues by gastroenterologists and tops the differential list for many liver lesions. However, this common disease can find rare ways to surprise even the very experienced, as occurred in the case of our 32 year old patient admitted for ascending cholangitis, later deemed secondary to intraductal invasion of hepatocellular carcinoma with a right lobe mass. Prognosis is generally better if a parenchymal mass is present. Isolated intraductal HCC is considered a third separate entity from HCC and cholangiocarcinoma with the suspicion that it arises either from intermediate cell line with features of both or as a concurrent "double-primary" malignancy. Both entities are uncommon processes with varied approaches to management of biliary obstruction. With exception of those transplanted, the management is palliative and generally focused on debulking and sometimes biliary stenting. We approached our case differently, opting for intraductal RFA as a palliative measure alongside chemoembolization of the primary mass.

CASE DESCRIPTION/METHODS:

A 32-year-old male with non-cirrhotic chronic hepatitis B presented with epigastric pain, vomiting, and serologic features of ascending cholangitis. Total bilirubin was 16.8 mg/dL, alpha fetoprotein 114 ng/mL, cancer antigen 19-9 1.0 U/mL. Imaging raised concern for HCC versus cholangiocarcinoma and he underwent percutaneous biopsy confirming moderately differentiated HCC. Magnetic resonance imaging raised concern for bile duct luminal irregularities. Endoscopic retrograde cholangiography that followed showed multifocal stenoses of a dilated biliary system and cholangioscopy was used to biopsy a polypoid mass near the biliary bifurcation. Pathology showed HCC. Endobiliary radiofrequency ablation was then employed endoscopically to ablate the intraductal lesions. Subsequent bilirubin 22 days later was 1.8 mg/dL. He suffered no complications related to intraductal RFA and experienced notable clinical improvement.

DISCUSSION:

While few cases are known and even fewer published, most intraductal HCC is diagnosed by percutaneous biopsy, exam of explant, or post-mortem. To our knowledge, this is the first described case demonstrating reliable diagnosis of intraductal HCC by single operator cholangioscopic biopsy and subsequent treatment with endobiliary RFA, highlighting the exciting potential of new technology used to treat an atypically presenting commonly encountered condition.
2177 Endoscopy-Directed Overtube-Assisted Vacuum Therapy of a Colo-Rectal Anastomotic Leak
Authors: Dukes Seth , Pinson Ross , Hawkins Jack , Cho Ryan
Published: October 2019

INTRODUCTION:

Colorectal anastomotic leak is a feared and potentially catastrophic complication of colorectal surgery. It presents an increase morbidity and mortality risk, hospital stays, cost and potential for repeat procedures. We present a case of development of an anastomotic leak managed with an overtube-assisted endoscopic vacuum therapy (EVT) under direct endoscopic visualization.

CASE DESCRIPTION/METHODS:

51 year old woman with a rectal cancer status post neoadjuvant therapy, low anterior resection (7 cm from the anal verge) and diverting loop ileostomy presented with a complaint of abdominal pain at 3 weeks post-op. A gastrograffin enema revealed contrast extravasation into the pre-sacral space confirming a colorectal anastomotic leak. The endoscopic exam revealed dehiscence of an end-to-end anastomosis at 7 cm from the anal verge, with a 2-cm defect that led to the pre-sacral cavity, measuring 6 × 4 cm in size. A polyurethane sponge was cut to the dimension of the cavity and sutured to a 16-Fr NG tube. A short overtube was placed into the opening of the cavity. The sponge was advanced through the overtube, under direct visualization, with a scope behind it. The tube was connected to a vacuum system for continued negative pressure at 175 mmHg. The procedure was repeated at a three-day interval. Over 7 sessions, the primary defect was completely sealed, reduced to 10% with diffuse granulation tissue formation. Serial barium enemas following treatment showed no evidence of extravasation or concern for persistent leak. On subsequent takedown of the ileostomy the patient was able achieve normal bowel function.

DISCUSSION:

Endoscopic treatment of anastomotic leaks has been proposed as an alternative to operative management in clinically stable patients with non-generalized peritonitis. Modalities include SEMS, pigtail stent placement and EVT . EVT was first described in 2008, which is proven to heal mucosal defects are placed at repeat intervals to allow for slow closure of the defect, with a higher success rate of 79% compared to other endoscopic modalities. No delivery system currently exists here in the states, allowing for the ease deployment of the sponge device. This case demonstrate that a short overtube (typically used for foreign body removal) can be used as a deployment device and highlights this unique way of advancing the sponge into the cavity using the scope as a pusher, allowing for direct visualization of the deployment.
2184 The First Case of Endoscopic Ultrasound Guided Liver Biopsy Followed by Endoscopic Sleeve Gastroplasty in the Same Session
Authors: Reja Debashis , Shahid Haroon , Tyberg Amy , Kahaleh Michel , Sarkar Avik
Published: October 2019

INTRODUCTION:

Endoscopic sleeve gastroplasty (ESG) is a novel procedure that is safe and effective for weight loss that has been shown to have significantly less morbidity than alternative bariatric procedures. We present the first case of Endoscopic ultrasound-guided liver biopsy (EUS-LB) done in the same session as ESG. Both procedures were without complications, and were technically and clinically successful.

CASE DESCRIPTION/METHODS:

28 year old female with hypertension and morbid obesity presented for elevated liver function tests concerning for NAFLD. In past 20 months patient went from 268 to 293 pounds and failed lifestyle interventions. Medications were Famotidine and Lipitor. Physical Exam was notable for obese female, increased waist circumference, nontender and non distended abdominal exam without rebound or guarding. CBC,BMP,PT/INR were within normal limits. Liver Function: AST 54 U/L, ALT 78U/L, Alkaline Phosphatase 56 U/L, Total Bilirubin 1.0 mg/dL. Ultrasound revealed hepatic steatosis, and FibroScan showed Fibrosis Score F4 consistent with cirrhosis. She did not have physical exam or lab findings consistent with cirrhosis. Patient was planned for ESG for weight loss and given Fibroscan results, same session EUS-LB was performed. EUS-LB was performed first in left lobe with 19 gauge FNB needle with no complications. ESG was performed successfully without complications. Upper GI series the next morning revealed no extravasation, patient tolerated diet and was discharged home. One month later, patient BMI decreased from 51kg/m2à45kg/m2, 298 to 263 lbs. No complaints of abdominal pain, nausea, vomiting and tolerating diet. Pathology from Liver Biopsy showed NAS Score 4/8 consistent with steatohepatitis, Stage 2-3 fibrosis.

DISCUSSION:

EUS-LB is an effective method for liver biopsy with minimal complications. ESG significantly reduces BMI with low morbidity . With the prevalence of NAFLD and subsequent conversion to NASH and cirrhosis increasing, non-invasive tests are utilized to stage fibrosis in patients with NASH. In cases where there is a discordance between clinical findings and Fibroscan results, liver biopsy can be obtained. This case demonstrates when a liver biopsy is indicated, EUS-LB is a safe and efficient option in a patient undergoing an endoscopy for other reasons. This is also the first reported case of EUS-LB and ESG in the same session. We demonstrate this procedure can be considered simultaneously in patients undergoing ESG to aid in weight loss for fatty liver disease.
2186 An Uncharacteristic Diagnosis of Small Cell, High-Grade Neuroendocrine Carcinoma of the Esophagus
Authors: Kubliun Maddie , Tran Minh , Agrawal Deepak
Published: October 2019

INTRODUCTION:

Small cell/high-grade neuroendocrine carcinoma of the esophagus is a rare malignancy, of which few cases have been reported in the United States. Here, we report the case of a young patient with small cell/high-grade neuroendocrine carcinoma of the esophagus to demonstrate its aggressive nature and the need for more effective therapy.

CASE DESCRIPTION/METHODS:

A 36-year-old man with recently-diagnosed type 2 diabetes presented with one month of jaundice, dysphagia, postprandial emesis, and 25-pound weight loss. Exam was notable for scleral icterus and jaundice with a benign abdomen. Labs revealed abnormal liver chemistries - AST of 244, ALT of 637, alkaline phosphatase of 309, GGT of 1353, total bilirubin of 10.6, direct bilirubin level 6.5. MRI of the abdomen showed thickening at the GE junction with enlarged adjacent lymph nodes, enhancing liver lesions and peripheral lesions in the pancreas. EGD revealed a mass in the lower third of the esophagus that obstructed the lumen. EUS showed invasion into the muscularis propria and enlarged regional lymph nodes. There was also a lesion in the pancreatic head leading to biliary obstruction. ERCP was performed and a stent was placed in the CBD with subsequent resolution of jaundice and improvement in liver chemistries. The biopsy of the esophageal mass revealed the following immunohistochemistry findings: synaptophysin (+), chromogranin (+), CDX2 (+), Ki67 proliferation index of 100%, p63 (-), and TTF-1 (-). The diagnosis was made of invasive high-grade small cell esophageal neuroendocrine carcinoma. Biopsy of the pancreatic mass revealed benign pancreatic acinar cells and ductal epithelium.

DISCUSSION:

Small cell/high-grade neuroendocrine carcinoma of the esophagus is rare and has a poor prognosis. It is an infrequent type of esophageal cancer and comprises <3% of all esophageal malignancies. It can occur in all age groups but is prominent in men during the fifth decade of life. IHC studies play an important role in the diagnostic process, but their application is limited in locating the primary site of the metastatic neuroendocrine cancer. CDX2 and TTF-1 have been shown to be effective in differentiating intestinal tract NEC from malignancy of the lungs and other locations. Treatment involves the use of chemotherapy that has been shown effective in small cell NEC in the lungs. More studies are needed to understand the biological features of this cancer, its diagnostic approaches, and a therapy regimen that provides better long-term survival rates.
2187 Successful EUS-Guided Gastrojejunostomy in Altered Anatomy After Failed Surgical Management
Authors: Mann Sarabdeep , Ahmed Shifat , Al-Jashaami Layth , Pitea Teodor
Published: October 2019

INTRODUCTION:

Endoscopic ultrasound (EUS) guided gastrojejunostomy is a recognized technique for relief of benign and malignant gastric outlet obstruction (GOO). This technique creates a fistulous tract between the stomach and the jejunum via placement of a lumen apposing metal stent. It has been shown to be technically and clinically successful in many patients with GOO, however its feasibility in the setting of altered postsurgical anatomy is less clear.

CASE DESCRIPTION/METHODS:

We present a 70-year-old female who underwent a laparoscopic cholecystectomy complicated by bile leak and duodenal perforation requiring a Roux-en-Y gastrojejunostomy. In the following year she developed GOO related to stenosis at the GJ anastomosis. Endoscopic placement of an esophageal covered metal stent across the anastomosis did not provide long term resolution of GOO and was followed by a second surgical revision of her gastrojejunostomy. Unfortunately, she continued to have significant nausea and recurrent vomiting. Repeat EGD and upper GI series showed persistent GOO at the level of the anastomosis. Therefore, a decision was made to attempt EUS guided gastrojejunostomy.

A gastroscope was advanced past the anastomosis and a guide wire was placed into the jejunum. Next, a 20 mm balloon catheter was advanced over the wire to the proximal jejunum using fluoroscopic guidance. An EUS echoendoscope was then inserted sideways to the balloon and used to identify the distended proximal jejunum in close proximity to the gastric wall. The jejunum was punctured under EUS guidance with a 19-gauge needle. A 0.025" guidewire was advanced through the needle under fluoroscopy into the proximal jejunum. A 15 mm × 10 mm AXIOS stent was advanced over the wire, and successfully deployed with the flanges in close approximation to the walls of the proximal jejunum and stomach. (Image 1). Upper GI series showed no evidence of leak and adequate gastric emptying across the gastrojejunal stent. The patient was discharged two days later on a low residue diet. Repeat EGD and upper GI series six weeks later showed no signs of GOO with a patent AXIOS stent (Image 2). At 6 month follow-up the patient continues to have complete resolution of nausea and vomiting.

DISCUSSION:

EUS guided gastrojejunostomy using lumen apposing covered metal stents can be a safe and effective option for management of GOO in patients with altered anatomy. However, there still remains need for long term follow up to determine the durability of such novel endoscopic interventions.
2189 Lavaging the Esophagus of Food Obstruction
Authors: Park Connie , Shenoy Vinayak , Nocerino Angelica , Ivanina Elena
Published: October 2019

INTRODUCTION:

Esophageal obstructions are usually due to a food bolus or foreign body ingestion in the setting of underlying esophageal disease. They are medical emergencies, requiring endoscopy within 24 hours of presentation, as failure to intervene can lead to perforation, fistula formation, or aspiration. Standard treatment consists of using a fiberoptic endoscope to advance the object into the stomach or retrieving it proximally. We describe the case of an esophageal obstruction from mashed potatoes. Due to its consistency, the obstruction could not be fully cleared with standard techniques and required an off-label use of gastric lavage for removal.

CASE DESCRIPTION/METHODS:

A 94-year-old female presented to our hospital complaining of three weeks of nausea, vomiting, and poor oral intake. Despite primarily consuming mashed potatoes, her symptoms worsened, with emesis of any solid foods or medications. She denied any history of dysphagia, esophageal dysmotility, or food impaction. Vital signs were stable and her abdominal exam was benign with no peritoneal signs. Abdominal computed tomography demonstrated a distal esophageal obstruction with proximal dilation. Upper endoscopy revealed food impaction with thick fibrinous food particles extending the entire length of the esophagus. Proximal retrieval with Roth Net retrievers, biopsy forceps, and tripod forceps was attempted for over two hours with minimal clearance. Given poor visualization and extent of esophageal involvement, the push technique could not be safely performed. Food particles repeatedly clogged the endoscope despite the use of diet ginger ale to break up the food. Hours later, success was finally achieved through gastric irrigation with the Ewald tube.

DISCUSSION:

Esophageal obstruction due to mashed potatoes is rare, and the standard methods of clearance may be ineffective at clearing its fibrinous content. Gastric lavage, routinely used in drug overdose to clear toxic ingestions, consists of inserting a tube (such as an Ewald tube) into the stomach via the mouth with sequential passing of water or saline to remove stomach contents. The same approach was applied to our patient to clear the fibrinous remnants adhering to her esophagus. This case appears to be the first reported use of gastric lavage to clear esophageal obstructions. When available, gastric lavage appears to be an effective method of managing esophageal soft food obstructions and may be considered as a last resort measure when all other methods have failed.
2191 EUS-Directed Transgastric ERCP (EDGE) for Removal of Cystic Duct Coils: A Novel Application of an Emerging Technique
Authors: Kumar Vikas , Parvataneni Swetha , Khara Harshit S. , Obuch Joshua , Deivert Duane , Khan Yakub
Published: October 2019

INTRODUCTION:

Presence of obesity as well as sudden weight loss, both predispose to gallstone disease. Post roux-en-y gastric bypass (RYGB) anatomy creates additional challenges for endoscopy and surgery. We present a captivating case of post-RYGB complicated gallbladder (GB) surgery, which eventually ends with coiling of cystic duct. The coil formed a nidus for infection and biliary obstruction, and the novel technique of EUS directed trans-gastric ERCP (EDGE) comes to the rescue.

CASE DESCRIPTION/METHODS:

A 27-year-old male with morbid obesity underwent RYGB. Over next 6 months, he lost 130 lbs (35% of total body weight). Three years after RYGB, he presented with acute calculous cholecystitis; requiring laparoscopic-converted to open cholecystectomy due to gangrenous GB and extensive adhesions. Postoperatively, a large cystic duct leak developed, requiring percutaneous transhepatic biliary drainage. Due to persistent leak IR-guided coil embolization of the cystic remnant was successfully done.After three years he presented again with RUQ pain, nausea and fever. CT showed cystic duct coil migration into the CBD with upstream dilation. An EDGE procedure with a 20 mm lumen apposing metal stent was performed with successful biliary sphincterotomy and biliary stones and sludge removal. The migrated coils were removed with a rotating action of the biopsy forceps advanced intraductally which facilitated wrapping of the coils around the forceps, and then removed with a snare.

DISCUSSION:

Obesity pauses high risk for cholelithiasis due to change in fat metabolism, hormonal regulation and GB motility. Significant weight loss further leads to gallstone formation. Our patient presented with acute calculous cholecystitis. Cholecystectomy was complicated by bile leak and led to percutaneous biliary (PTC) drainage. Lap-assisted ERCP could not be performed due to high risk of morbidity in this patient. Instead of PTC and coil placement, EDGE may have been a better option at that point. Patient ended up requiring EDGE due to development of cholangitis associated with biliary obstruction due to migrating cystic duct coils. In this complicated young patient with abdominal adhesions, EGDE was a saving grace, as the alternative may be to live with PTC drain lifelong.
2192 Endoscopic Drainage of a Perirectal Abscess Into the Rectal Lumen With a Lumen-Apposing Metal Stent Avoiding Percutaneous Drainage and the Presence of a Trans-Gluteal Catheter
Authors: Pineda Bonilla Jonh J.
Published: October 2019

INTRODUCTION:

A 37-year-old woman developed abdominal pain, and diarrhea six weeks after a total hysterectomy with bilateral Salpingo-Oophorectomy was performed for a benign indication. A computer tomography (CT) scan of the abdomen and pelvis with intravenous contrast showed a perirectal abscess, measuring 6.2 × 5.7 × 6.1cm Figure 1. The perirectal abscess was drained transrectally by placement of a cautery enhanced 10 × 10 mm lumen opposing metal (LAM) stent, creating a fistula between the abscess and the rectum.

CASE DESCRIPTION/METHODS:

Using a transrectal approach, the perirectal abscess was imaged by endoscopic ultrasound (EUS). Under doppler ultrasound and fluoroscopic guidance, the abscess was punctured with a 19gauge fine needle aspiration (FNA) needle. A 450cm x 0.025-inch wire was passed through the needle and allowed to coil multiple times in the abscess for stability. The LAM stent was advanced over the wire 4 cm into the abscess and deployed in position Figure 2. There were no complications. Three weeks after the endoscopic placement of the LAM stent, a CT scan showed complete resolution of the perirectal abscess Figure 3. The same week, the stent was removed endoscopically without complications.

DISCUSSION:

This case demonstrates that LAM stents can be safely use for drainage of perirectal abscesses and non-malignant, wall mature perirectal fluid collections. The dumbbell shape design of the stent keeps the fistula tract intact preventing leaks and decreasing the incidence of stent migration and perforations. To safely deploy the distal end of the stent inside the fluid collection, the stent's catheter needs to be advanced 4 cm into the collection before deployment. If this is not accomplished the distal end of the stent may be deployed outside of the fluid collection causing a perforation. If a stable position of the EUS scope is secured there is no need to puncture the fluid collection with a 19-gauge FNA needle, nor to pass the wire into the cavity, because it can be directly accessed with the cautery enhanced tip of the stent's catheter affording a much shorter procedure time.Cases of bleeding have been reported after the collection has been drained and the cavity has collapsed; it is therefore suggested that the optimal time for stent removal is three weeks after stent placement once the fistula tract has been formed and resolution of the collection is confirmed by cross sectional imaging.
2194 Prevention of Excessive Gas Accumulation With a Biliary Dilation Balloon During Endoscopic Cryotherapy
Authors: Abadir Alexander , Clary Meredith , Samarasena Jason , Chang Kenneth J.
Published: October 2019

INTRODUCTION:

Endoscopic cryotherapy for the treatment of premalignant and malignant conditions has been demonstrated to be an effective tool in esophageal malignancy. However, there is concern for perforation from gas production during cryotherapy. Here we describe the use of a biliary dilation balloon to prevent distal gas accumulation in Roux-en-Y anatomy.

CASE DESCRIPTION/METHODS:

This is a case of a 77-year-old male with history of total gastrectomy with Roux-en-Y esophagojejunostomy for remote history of gastric leiomyosarcoma and locally advanced esophageal cancer. Two years prior he underwent Endoscopic Submucosal Dissection (ESD) of an esophageal nodule previously biopsied positively for adenocarcinoma. One year ago a surveillance EGD/EUS with biopsy showed no evidence of residual disease at the ESD site. Repeat surveillance EGD/EUS early this year identified thickening of subepithelial layers with a 6mm hypoechoic lesion at the level of the ESD scar. A hybrid ESD and endoscopic mucosal resection (EMR) technique was performed to remove the nodule. Pathology showed invasive poorly differentiated adenocarcinoma with the deeper cauterized margin involved. Endoscopic cryoablation was planned for the remaining margins. Close examination of the ESD defect using EGD and EUS showed no evidence of recurrence. Cryotherapy was then prepared with the insertion of a biliary dilation balloon via a nasal trumpet. The balloon was endoscopically guided to the jejunum distal to the esophagojejunal anastomosis and inflated to prevent distal leakage of cooling gases. A decompression tube was placed in the esophagus proximal to the treatment area. Using the cryocatheter, 3 treatments of liquid nitrogen at -190⁰ C were sprayed over the ESD scar to achieve uniform white frost, each treatment lasting 30 seconds with 60 seconds of defrost time between. Throughout the treatment, suction was provided via the decompression tube and the abdomen was palpated without significant distention. The patient tolerated the procedure well without complication and was discharged home.

DISCUSSION:

Gas by-products are produced during cryotherapy, which in the case of a patient with a Roux-en-Y, causes substantial risk for perforation. With a distally inflated biliary dilation balloon, gas is prevented from accumulating in the small intestine where it may be difficult to suction, reducing the risk of perforation. This technique may be applied to similar cases where perforation risk is elevated.