bluuebunny/crossref_metadata_2025 huggingface dataset:
1149 Endoscopic Signs Moderately Correlate With Histologic Changes in Children With Eosinophilic Esophagitis
Authors: Hiremath Girish , Tyree Regina N. , Correa Hernan , Acra Sari , Dellon Evan S.
Published: October 2019

INTRODUCTION:

Management of children with eosinophilic esophagitis (EoE) could be simplified if the endoscopic signs strongly correlated with tissue level changes and served as a marker for mucosal healing. Accordingly, we tested the hypothesis that endoscopic signs would strongly correlate with histologic changes in children with EoE.

METHODS:

We consecutively enrolled 115 children with EoE (active EoE, defined as ≥ 15 eos/hpf, n = 62; inactive EoE, < 15 eos/hpf, n = 53) undergoing endoscopy with biopsies. Their demographic and clinical information was gathered. EoE relevant endoscopic signs (edema, rings, exudates, furrows, stricture) were recorded per the endoscopic reference scoring system (EREFS). Esophageal biopsies were assessed for both peak eos/hpf and the EoE Histology Scoring System (EoEHSS). Correlation between EREFS and peak eos/hpf or EoEHSS was evaluated using Spearman’s rho (r), and multiple linear regression analysis was used to adjust for confounders such as age, gender, ethnicity, duration of EoE, medication exposure, allergic co-morbidities, and disease status.

RESULTS:

The average age of our cohort was 9.4 ± 3.6 years, 77% were white and 73% were male. Overall correlation between EREFS and EoEHSS was marginally stronger [r = 0.60; P < 0.001] but not statistically significant when compared to peak eos/hpf [r = 0.55; P < 0.001]. In children with inactive EoE, the EREFS moderately correlated with eos/hpf [r = 0.44; P = 0.001] and EoEHSS [r = 0.46; P < 0.001]. However, in children with active EoE EREFS weakly correlated with EoEHSS [r = 0.32; P = 0.01] and did not significantly correlate with eos/hpf [r = 0.10; P = 0.41]. Regression analysis revealed that EREFS was positively associated with EoEHSS [ß = 1.66 (95% CI: 0.65-2.68); P = 0.002], and active EoE [0.60 (0.06-1.15); P = 0.02)], presence of dysphagia [0.75 (0.16-1.33); P = 0.01], and a history of eczema [-0.67 (-1.10- -0.24); P = 0.002] were other independent predictors. The association between EREFS and peak eos/hpf after adjusting for potential confounders did not attain statistical significance.

CONCLUSION:

Endoscopic signs only moderately correlate with histologic changes in children with EoE, particularly in children with inactive EoE. The variability in mucosal involvement and the severity and intensity of tissue level inflammatory alterations may explain the weak relationship in children with active EoE. As such, monitoring both endoscopic healing and histologic changes remains central to the management of children with EoE.
1161 Learning Styles and Burnout in Gastroenterology: Should Continuing Medical Education Be Changed to Accommodate all Learning Styles?
Authors: Bledsoe Adam C. , Stephenson Christopher , Mahapatra Saswati , Schleck Cathy , Mandrekar Jay , Collins C. Scott , Sanchez William , Ravi Karthik , Wittich Christopher , Raffals Laura E.
Published: October 2019

INTRODUCTION:

Learning styles among gastroenterology providers have not been reported and may have implications in improving continuing medical education (CME). This study aims to 1) evaluate learning styles among gastroenterology providers participating in a board review course, 2) assess self-reported burnout, and 3) determine if demographic information, practice style, or burnout was associated with specific learning styles.

METHODS:

Participants at the 2018 Mayo GI and Hepatology Board Review Course had the opportunity to participate in an anonymous, survey-based study evaluating learning styles and burnout. Demographic and practice information, reason for participating in the course, questions regarding burnout and callousness, and the Kolb Learning Style Inventory (KLSI) (v3.1, Korn Ferry Hay Group, Boston, MA) were collected. Associations between demographic data, burnout, and learning styles were assessed using Fisher’s exact test.

RESULTS:

A total of 71 of 230 participants elected to participate and 47 completed the KLSI. Median age range was 41-50 years, 31 (43.7%) were female, and 60 (84.5%) had MD or DO degree. All regions of the United States were represented and 4 participants were from outside of the US. Reasons for participation included new certification (12.7%), recertification (45.1%), not passing prior board certification (4.2%), and general knowledge (38%). Burnout was noted by 27 (38%), callousness by 19 (26.8%), and both by 9 (12.7%). Kolb learning styles were diverging in 27.7%, assimilating in 31.9%, converging in 27.7%, and accommodating in 12.8%. There were no associations with demographics, practice type or reason for taking the course with specific learning styles; however, more frequent markers of burnout were associated with the accommodating learning style (50% burnout only, 33% callous only, and 16.7% reporting both; P = .03).

CONCLUSION:

All learning styles are represented at the studied board review course and are dispersed throughout ages, sex, geography, and practice style. This highlights the importance of a transition from lecture-based CME to more varied education modalities. Indices of self-reported burnout are seen frequently in this cohort, and seem to have increased association with the accommodating learning style. Future study with more participants is needed to further understand learning styles and burnout in gastroenterology providers, with the aim of improving CME.
1185 Predictors of Hospital Readmission Among Patients With Obscure Gastrointestinal Bleeding Following Inpatient Capsule Endoscopy
Authors: Levine Irving , Hong Soonwook , Bhakta Dimpal , McNeill Matthew B. , Gross Seth , Latorre Melissa
Published: October 2019

INTRODUCTION:

Patients with obscure gastrointestinal bleeding (OGIB) often require frequent hospital admissions and endoscopic procedures to identify and treat bleeding. Capsule endoscopy (CE) provides a novel approach to evaluate OGIB. The role of inpatient CE in hospital readmissions has not been previously reported. We sought to identify patient and clinical factors associated with hospital readmission among patients with OGIB following inpatient CE.

METHODS:

We conducted a retrospective review of adult patients undergoing inpatient CE at a tertiary referral, academic medical center between 4/1/17 and 4/1/19 to evaluate for predictors of readmission. We reviewed patient demographics, medical history, medications, hospital course, results of CE, and 30-day readmission rates. Arteriovenous malformation (AVM) risk factors were defined as having comorbid cardiac valvular disease or advanced chronic kidney disease (stage 3-5). A positive CE was defined as having abnormal small bowel pathology or bleeding.

RESULTS:

86 patients were included. Overall, 64% were male with a median age of 69 years (Table 1). The main indication for inpatient CE was overt bleeding (59%). Complete CE was noted in 70 patients (81%), and positive CE in 48 patients (56%). Overall, 17 patients (19.8%) were readmitted within 30 days of index admission. Length of stay (LOS) on index admission was longer among those readmitted (Mean LOS 10 days vs 7.9 days, P = 0.07). Readmission was not related to age, gender, complete CE, positive CE or bleeding on CE. There was a trend for readmission among patients who had previously been admitted within 30 days (41% vs 22%, P = 0.1). There was a trend towards readmission for patients with diabetes mellitus (DM) and AVM risk factors. Medication use was not associated with readmission.

CONCLUSION:

Patient with OGIB have high rates of hospital admission. The use of inpatient CE can provide guidance on subsequent therapy in patients with OGIB, with the potential to decrease hospital admissions. We found high rates of 30-day hospital readmission among patients with OGIB after inpatient CE. No significant predictors of readmission were noted, though several factors, including increased LOS on index admission, DM, AVM risk factors, and recent admission trended towards readmission. Larger studies are necessary to fully elucidate predictors of readmission. To our knowledge, this is the first study to address the effect of inpatient CE and hospital readmissions.
1204 Could Pyloroplasty Combined With Gastric Electrical Neurostimulation Be the Optimal Treatment for Drug Refractory Gastroparesis Based on Pyloric Pathology, Clinical and Gastric Emptying Results?
Authors: Shanker Aaron , Padilla Osvaldo , Bashashati Mohammad , Espino Karina , Vega Natalia , McCallum Richard , Sarosiek Irene
Published: October 2019

INTRODUCTION:

Gastric electrical neuro-stimulation (GES) therapy for severe gastroparesis (GP) was approved under the Humanitarian Device Exemption (HDE) status in March of 2000. The lack of improvement in gastric emptying (GE) with GES generated our interest to supplement GES with a simultaneously performed pyloroplasty (PP). The aim of our investigation was to assess the long term effects of GES + PP on GE results and GP symptoms, while documenting the pathology of the pyloric smooth muscle.

METHODS:

Overall, 29 GP drug-refractory patients (19) diabetics (DM) with a mean 14.4 ± 7.3 years of DM, 8 idiopathic, and 2 post-vagotomy (PV) underwent surgical implantation of GES with the Heineke-Mikulicz PP. Biopsy of pyloric smooth muscle was obtained, and all samples were stained with C-Kit to identify the status of Interstitial Cells of Cajal (ICC) and trichrome for fibrosis. GP total symptoms score (TTS) of vomiting, nausea, early satiety, bloating, fullness and epigastric pain, were assessed with 5-point Liekert scale, and GE 4-hour scintigraphy test was performed before surgery and at the last follow-up visit.

RESULTS:

29 patients, mean age 47 ± 14 years (range 21-78); 21 F; with mean 5.5 (1-20) years of GP symptoms were included in this observation. Overall, TSS improvement after a mean follow-up of 35 months (6-72) post-surgery was 58% (8-100) (Table 1), but 48% of GP patients improved their symptoms by >65% after GES + PP, and ED visits and days of hospitalizations were significantly reduced. GE tests showed 77% (range 53-100) retention at 2 hour and 48% (15-100) at 4 hour before the therapies, and these results improved to 40% (3-94) at 2 hour, and 14% (0-58) at 4 hour. Also, 83% patients normalized their GE at 2 hour, and 62% normalized at 4 hour (less than 10% retention) (Table 2). Interestingly, GE remained the most delayed (58%) at 4 hour in PV GP patients. Pyloric ICC depletion (≤10 ICC/HPF) was present in 75% of patients, with a mean 7 ICC/HPF, while 80% of them had minimal/moderate amount of collagen fibrosis between the muscle bundles. There were no unanticipated SAE's or technical problems reported during this study.

CONCLUSION:

GP drug-refractory patients, responded to combining GES and PP with a significant long-term symptom improvement (60%) and accelerated gastric emptying, which normalized in the majority of patients. The depleted ICC and fibrosis in the pyloric smooth muscle justifies the addition of PP to GES, and explains its success.
1227 Home Initiated Parenteral Nutrition Is a Safe and Cost-Effective Approach to Nutrition Support
Authors: Haselhorst Jamie , Brown Rebecca L. , Cooper Casey , Slate Shannon , Stevenson Debbie , Ogden Diana
Published: October 2019

INTRODUCTION:

Home initiation of parenteral nutrition (PN) has been a successful practice for over 20 years. Some healthcare teams are not comfortable initiating PN in the home setting. The principal concern is related to patient safety and the risk of refeeding syndrome. The primary purpose of this study is to evaluate the safety and efficacy of home start PN. With increasing costs associated with the provision of healthcare, a cost-analysis is an important secondary factor to consider.

METHODS:

The study was approved by the pharmacy's clinical compliance team. Protected health information was not included, informed consent was not required. A retrospective chart review was conducted on adults >18 years of age that started on home PN between 6/1/2017 and 6/30/2018. We excluded individuals when therapy was less than 30 days. Data included the occurrence of hospitalizations, ER visits, central venous access device events (CVAD) and Adverse Drug Reactions (ADRs) in the first 30 days of therapy. Incidence of refeeding syndrome was determined for the home initiated PN patients. The number of days it took home start PN patients to reach caloric goal, defined as goal calories outlined in the initial nutrition assessment, was obtained. The sample groups were analyzed using a two-sample t-test (assuming equal variances) with one-tailed P values to demonstrate statistical significance.

RESULTS:

62 home start PN patients met criteria. 62 patients from the same geographical locations who started PN during the same time in the hospital setting were randomly selected as a control group. A statistically significant (P < 0.05) improvement in 30-day hospital readmissions was demonstrated in the home start PN group (P = 0.02). Using a 95% confidence interval, statistical non-inferiority was demonstrated in the number of ER visits, CVADs, and ADRs in the home start PN group (Figure 1). The incidence of refeeding syndrome in the home start population was 11.11%, which is comparable to previously published studies. Avg. days to goal for the home start PN patient was 9.7 days (Table 1).

CONCLUSION:

Patients with home initiated PN had fewer hospital admissions after starting therapy than hospital start PN. Home start PN provides a cost savings of approximately $2000 per day (Figure 2). Starting PN in the home setting reduces exposure to hospital acquired infections in patients. Home start PN is a safe alternative and should be considered given the cost savings, fewer readmissions, and preventing hospital-acquired infections.
1263 Endoscopic Management of a Surgical Clip Found Within the Common Bile Duct Following Remotely Performed Laparoscopic Cholecystectomy
Authors: Rastegari Sheila , Brewer Curtis , Hoang Long
Published: October 2019

INTRODUCTION:

Minimally invasive surgery with surgical clip placement has become the gold standard for management of cholecystitis and biliary colic due to its favorable safety profile and low risk of complications. Though generally safe, surgical clips can serve as a source of complication years after cholecystectomy by migrating into the common bile duct and serving as a nidus for stone formation. To date, very few cases of this have been reported. While uncommon, this complication should be considered in the differential diagnosis for choledocholithiasis and cholangitis.

CASE DESCRIPTION/METHODS:

Here we present a 35-year-old female with a past medical history of invasive rectal adenocarcinoma who underwent laparoscopic cholecystectomy over ten years ago. She presented to the hospital with a two-week history of RUQ abdominal pain, chills, and nausea. Physical exam showed scleral icterus and RUQ abdominal tenderness. Labs showed elevated WBC count and LFTs in a cholestatic pattern. Patient was started on antibiotics for suspected cholangitis and underwent MRCP which suggested presence of metallic clip within the common bile duct. Subsequent ERCP revealed large stone impacted against the ampulla of Vater. Sphincterotomy and balloon sweep of the common bile duct were performed with extraction of large stone formed around surgical clip, followed by release of copious amount of purulent bile. Following procedure LFTs showed downward trend and symptoms resolved.

DISCUSSION:

Though the exact incidence and mechanism of surgical clip migration into the common bile duct is unknown, it is thought to be a slow process with the potential for subsequent stone formation years after surgery. Clinical presentation is the same as non-iatrogenic choledocholithiasis. In most reported cases, stone extraction required surgical intervention due to large size. Here we present a case successfully managed with sphincterotomy and balloon extraction over ten years after laparoscopic cholecystectomy. Though rare, the potential for surgical clip within the common bile duct serving as a nidus for stone formation should be considered in post-cholecystectomy patients presenting with symptoms of choledocholithiasis and cholangitis, regardless of how recently surgery was performed. Minimally invasive surgery and the use of surgical clips has become almost ubiquitous; thus clinicians should be aware of this possible complication and options for management.
1270 Unexpected Microorganism in an Unexpected Place
Authors: Alameri Aws , Museedi Abdulrahman S. , Echavarria Juan
Published: October 2019

INTRODUCTION:

Candida Parapsilosis (CP) has been implicated in several intra- and extra- vascular infections and rarely been the cause of intraabdominal infections. We describe a case of CP infection complicating acute severe necrotizing pancreatitis.

CASE DESCRIPTION/METHODS:

A 68-year-old man presented with acute onset epigastric pain associated with nausea and vomiting. Physical examination revealed epigastric tenderness. Lipase was elevated at 7352 mg/dl and initial abdominal CT scan revealed changes consistent with acute edematous pancreatitis with possible early necrosis. His clinical course was complicated by acute respiratory failure, septic shock, and AKI requiring hemodialysis. He was in and out of the intensive care unit despite medical management including nutrition support and broad spectrum antibiotics. A repeat CT scan 4 weeks later showed acute necrotizing pancreatitis with walled-off necrosis (WON). After an episode of acute decompensation, a percutaneous drain was placed prior to necrosectomy. The aspirated fluid grew Candida Parapsilosis and patient was started initially on Micafungin, and then transitioned to oral fluconazole. Soon after starting antifungals the patient stabilized, clinically improved and was able to be discharged home. He subsequently underwent a video assisted retroperitoneal dissection, which revealed a small amount of necrosis and a pancreatic duct leak into the WON. He underwent ERCP with pancreas duct stent bypassing the leak. Upon most recent visit, patient showed considerable improvement.

DISCUSSION:

The incidence of CP infections has been greatly increased over the last decade. Primarily, CP is implicated in cases of fungemia accounting for 3–27% of all cases of in large studies and to lesser extent in extravascular infections like osteomyelitis. Intraabdominal infections are unusual and mostly associated with peritonitis complicating surgery and peritoneal dialysis. Despite the organism normally colonizes the GI tract, pancreatic infections by CP are rare, and are usually complicating acute pancreatitis. They could be explained by portal extension and be predisposed by use of broad spectrum antibiotics, surgery, and instrumentation. In conclusion, it is important to consider fungal infections in cases of complicated infected pancreatitis especially those not responding to broad spectrum antibiotics as they share similar clinical features with bacterial causes and prompt diagnosis and treatment are key to a better outcome.
1289 Transverse Colonic Stricture in a Patient With Recurrent Necrotizing Pancreatitis
Authors: Ahmed Sagah , Choden Tenzin , Shafa Shervin
Published: October 2019

INTRODUCTION:

An isolated colonic stricture is a rare sequela of recurrent pancreatitis, but may present a diagnostic challenge as it presents similarly to more common etiologies of isolated colonic stricture, such as inflammatory bowel disease (IBD) and malignancy.

CASE DESCRIPTION/METHODS:

A 48-year-old man with a history of alcohol–induced recurrent necrotizing pancreatitis requiring multiple debridements presented with a week of colicky right- sided abdominal pain and constipation. CT abdomen revealed markedly distended cecum and ascending colon, a 13-cm mid-transverse colonic stricture with marked associated stranding, and a 6-cm intra-pancreatic fluid collection. The isolated colonic stricture was thought to be due to either colonic ischemia secondary to his history of multiple episodes of severe necrotizing pancreatitis, or extrinsic compression by the pancreatic fluid collection on the transverse colon. Initial workup showed mildly elevated inflammatory markers and ascitic fluid cytology, which was negative for malignancy. On imaging, it was unclear if the stranding in the bowel was contiguous from the peri-pancreatic inflammation. See Figures 1 and 2. Colonoscopy was attempted but the colonoscope could not be passed beyond 50 cm due to marked tortuosity. The visualized portions of the mucosa appeared normal. The patient underwent a laparoscopic diverting loop ileostomy, during which narrowing of the mid-transverse colon was noted to be grossly consistent with cicatricial reaction to prior severe necrotizing pancreatitis, with adherence to the pancreatic head and neck. No neoplastic process was noted, and there was no necrotic tissue or abscess visualized. The strictured area was thought not to be amenable to resection given the frozen nature and presence of large peri-gastric and peri-colic varices and thus diverting loop ileostomy was performed along with adhesiolysis.

DISCUSSION:

Colonic stricture is a rare sequela of acute or chronic pancreatitis, which is thought to occur as a consequence of diffusion of ischemia and necrosis through the mesentery to the colon. Alternatively, it has also been suggested that pancreatitis may lead to colonic stricture by way of extrinsic compression on the colon by a pancreatic pseudocyst. Although rare, in the appropriate clinical context, clinicians may consider acute and chronic pancreatitis as possible etiologies of isolated colonic stricture along with more common etiologies.
1439 A Rare Presentation of Sarcoidosis Diagnosed as Pancreatic Sarcoidosis
Authors: Shukla Kushal , Rahni David
Published: October 2019

INTRODUCTION:

Sarcoidosis is non caseating granulomatous multi system inflammatory disease of unknown cause affecting many worldwide. In 95% cases, pulmonary and mediastinal lymph nodes are involved. Pancreaticobiliary involvement is exceedingly rare 1-6%. Clinically recognizable gastrointestinal sarcoidosis occurs in 0.1 to 0.9% of patients. Pancreatic sarcoid can mimic clinical and radiological findings associated with tuberculosis and malignancy.

CASE DESCRIPTION/METHODS:

Here, we present a 50-year-old male patient male with past medical history of diabetes, hypertension, hyperlipidemia and treated syphilis presented to ED with diarrhea, abdominal pain and shortness of breath. Physical exam was significant for hypoxemia with O2 sat 92% on room air and ascites with shifting dullness. Labs were unremarkable including normal lipase ad liver function tests. CTA of chest showed no pulmonary embolism but had enlarged peripancreatic, periceliac, mediastinal lymph nodes with nodular liver. MRCP showed patent pancreatic and biliary duct with right sided compressive atelectasis and nodular contour liver without focal hepatic lesions. No focal masses or inflammatory changes seen within pancreas but showed small focal lesions posterior to pancreas at the level of celiac axis measuring 11 mm and 7 mm read as nonspecific pancreatic lymphadenopathy. EUS directed biopsy of peripancreatic lymph node was significant for non caseating granuloma with negative Acid fast stain and nonmalignant cells. Patient's ascites and oxygenation improved after dexamethasone treatment.

DISCUSSION:

On literature review patients with pancreatic sarcoidosis have abdominal pain 66%, weight loss 49%, obstructive jaundice 29%, emesis 20%, pruritus 12%, fever 8%, diarrhea 4%, abdominal distention 4% and ascites 4%. Lymphadenopathy is the most common findings on imaging with most common hilar and paratracheal 90% to very uncommon intraabdominal lymphadenopathy 30%. Tissue biopsy of the pancreatic lymph node is required to differentiate pancreatic sarcoidosis from other inflammatory and malignant disorders of the pancreas as laboratory findings are not specific for diagnosis. The prognosis of mild pancreatic sarcoidosis is good and in severe form its variable. Corticosteroid is the drug of choice and remission rate in severe form after stopping is 100%. Non steroidal drugs have been used for treatment of some refractory life-threatening forms of sarcoidosis such as methotrexate, hydroxy chloroquine and azathioprine.
1494 Padlock Clip in the Management of Non-Lifting Part of Incompletely Resected Polyp With Central Fibrosis
Authors: Mouchli Mohamad , Walsh Christopher , Shakhatreh Mohammad , Yeaton Paul , Chitnavis Vikas
Published: October 2019

INTRODUCTION:

Removing nonlifting colon polyps with fibrosis secondary to prior intervention could be challenging. The novel over-the-scope Padlock clip was used in esophageal fistulas, refractory gastrointestinal bleeding, and GI defects closure. In this study, we describe our experience with Padlock clip in remeoving nonlifitng colon polyp.

CASE DESCRIPTION/METHODS:

A 69-year-old man is referred to our clinic to assist in the management of partially excised large, non-granular, broad-based Tubulovillous adenoma. The polyp was in cecum and measured about 5 cm. The patient underwent surveillance colonoscopy given personal history of colon polyps and paternal history of colorectal cancer. The referring physician attempted to remove by standard and Captivator snares using hot snare techniques. The polyp was not completely engaged, and the resected fragments were removed using roth net. We attempted to lift the polyp to remove using endoscopic submucosal dissection, but the scar mark could not be lifted. After marking around the polyp using electrosurgical knife (Figure 1), endoscopic submucosal dissection was done around the polyp with gradual extension of the circumferential mucosal incision, followed by hot snare-assisted resection of the lesion in a piecemeal fashion. The Non-lifting part of mucosal polyp was then grasped with raptor grasping device and Padlock clip was deployed on the polyp. The remnant polyp was successfully removed with hot snare utilizing “histlock resection device” and the margins were treated with tip of hot snare (Figure 2). Repeat colonoscopy after 3 months showed scar at previous polypectomy site with clean margins and no signs of recurrence (Figure 3).

DISCUSSION:

To our knowledge, this is the first study describing the use of of Padlock clip in the management of nonlifting colon polyp after incomplete resection using the conventional methods. The Padlock clip was used in the management of refractory gastrointestinal bleeding (post endoscopic mucosal resection, solitary rectal ulcer, and duodenal dieulafoy lesion), broncho-esophageal and tracheoesophageal fistulas closure, and wall defects closure in porcine. Further prospective studies are needed to assess its use in removing incompletely resected polyps.
1500 The Incidental Raised White Lesion: A Case of Indolent Mastocytosis
Authors: Bazarbashi Ahmad Najdat , Saltzman John
Published: October 2019

INTRODUCTION:

Mastocytosis results from clonal proliferation of abnormally defective mast cells. The clinical presentation of mastocytosis can be heterogeneous, ranging from indolent disease to aggressive systemic mastocytosis, which can present with syncope, recurrent flushing, diarrhea, and abdominal pain. We present a case of an asymptomatic patient presenting for surveillance colonoscopy, found to have an isolated elevated white lesion in the colon which on biopsy was mastocytosis.

CASE DESCRIPTION/METHODS:

A 68-year-old man with history of hypertension and hyperlipidemia presented for surveillance colonoscopy. His last colonoscopy was five years prior and revealed one small adenomatous polyp. Vital signs were within normal limits and physical examination was unremarkable. He denied symptoms of flushing, pruritus, abdominal pain, nausea or vomiting. Colonoscopy revealed an isolated white, raised area of mucosa, measuring 5 mm in diameter which was encountered at the transverse colon (Figure 1). Biopsies of this area was obtained. Pathology of the elevated white mucosal area showed marked eosinophilic infiltrate admixed with round to spindle cells that stain positive for KIT and CD25. These findings are consistent with involvement by an abnormal mast cell infiltrate. The patient's complete blood count was normal and serum tryptase level was within normal limits. Given these findings, his diagnosis was consistent with asymptomatic indolent mastocytosis. He was recommended to have yearly complete blood count, liver function tests and tryptase level, in addition to bone density screening, bone marrow biopsy and close follow up with hematology and gastroenterology.

DISCUSSION:

Mastocytosis results from clonal proliferation of abnormal mast cells which can accumulate in the bone marrow, skin and other organs including the gastrointestinal tract. Gastrointestinal findings on colonoscopy can include normal mucosa, raised white-colored mucosa, polypoid lesions and ulcers or erosions involving the upper or lower gastrointestinal tract. While many patients with gastrointestinal tract involvement have symptoms of abdominal pain, nausea and diarrhea, this case highlights the importance of recognizing the endoscopic manifestations of asymptomatic indolent mastocytosis.
1575 Colouterine Fistula: A Rare Crohn's Complication
Authors: Sundaram Suneha , Lopez Luis Rauseo , Gollol Raju Narasimha Swamy , Harvin Glenn
Published: October 2019

INTRODUCTION:

Colouterine fistulas are a rare complication of gastrointestinal diseases, mostly described as a complication of diverticulitis in elderly patients. Colouterine fistula as a complication of Crohn's disease is exceptionally rare. We present a young Caucasian female with history of poorly controlled Crohn's disease presenting with colouterine fistula.

CASE DESCRIPTION/METHODS:

26-year-old Caucasian female with ileal Crohn's disease since 2014 presented with abdominal pain and fever. Her PMH was significant for poor compliance with medications and follow ups. In the preceding 6 months she had a complicated clinical course including a flare with SBO and intraabdominal abscess while she was 23 weeks pregnant needing resection of TI and cecum with a diverting ileostomy followed 2 weeks later by a miscarriage, drainage of a perirectal abscess, fistula between loops of small bowel, and ileostomy take down followed by an abdominal wall abscess needing drainage. She had been lost to follow up and had not been on any medications the preceding one year. Her last colonoscopy was prior to ileostomy take down and had shown healthy appearing ascending colon stump, mild erythematous mucosa throughout the colon with no pathologic evidence of Crohn's and a well healing perianal fistula site. At presentation, ESR was 70 mm/h and CRP 81 mg/L. CT abdomen was read as a large peripherally enhancing fluid collection within the right lower abdomen and pelvis and mildly thickened neoterminal ileum. An abscessogram however showed the fluid collection was a large colouterine fistula filling the ascending colon at the anastomosis and both Fallopian tubes. Patient has been started on induction therapy with adalimumab and discharged with slow prednisone taper with plans to follow up for continued adalimumab therapy as well as evaluation at a facility with specialty Uro-Gynecology resources for fistula correction.

DISCUSSION:

Fistulas between small bowel and uterus in Crohn's disease has been described in literature. Fistulas between colon and uterus in Crohn's disease is exceptionally rare; to date only two cases have been reported, a sigmoid colouterine fistula and rectouterine fistula. The thick uterine wall is considered to be a protective factor against fistula formation, but prior colonic surgery or disruption of uterine wall integrity may predispose to fistula formation in Crohn's disease. Our patient had a recent ileocecectomy which was likely contributory to colouterine fistulization in the setting of poor compliance.
1581 Sequential Fecal Microbiota Transplantation for Severe Acute Refractory Clostridium difficile Colitis: A Life-Saving Treatment Approach
Authors: Kilakkathi Sindhu , Shah Rushikesh , LeVert Francis Edward
Published: October 2019

INTRODUCTION:

Fecal microbiota transplantation (FMT) is now a commonly used mode of treatment for recurrent Clostridium difficile infection (rCDI) refractory to antibiotics. We report a unique case where two sessions of sequential FMT were used to treat acute rCDI refractory to antibiotics with endoscopically documented marked improvement in disease process.

CASE DESCRIPTION/METHODS:

A 69 year-old female presented with 4 days of fever, large volume non-bloody diarrhea and poor appetite. She denied abdominal pain, nausea or vomiting. She reported two months before this admission, she was treated for hospital-acquired CDI, but could not recall what she was treated with. Physical examination revealed a non-tender abdomen without guarding or rigidity. Laboratory tests revealed hemoglobin 11.3 g/dL and white blood cell (WBC) count 18,700/mcL. Stool testing was positive for C. difficile toxin assay. Computed tomography of the abdomen showed diffuse pancolitis, compatible with CDI, no evidence of bowel perforation or obstruction. Despite treatment with oral vancomycin (500 mg every 6 hours), intravenous metronidazole and probiotics for 5 days, her leukocytosis increased to 32,000/mcL, hemoglobin dropped to 6 g/dL and her symptoms persisted. The decision was made to try FMT and antibiotics were stopped for 48 hours as per FMT protocol. Colonoscopy showed severe pancolitis (Figure 1) and pseudomembranes consistent with severe C. difficile colitis with distal ascending colonic mucosa concerning for ischemia. 250 mL of donor stool was delivered at the proximal transverse colon. After the first FMT, mild improvement was noted in her symptoms and leukocytosis but she persisted to have severe diarrhea. A second FMT was performed 4 days later. Repeat colonoscopy (Figure 2) showed marked improvement in the appearance of pancolonic erythema, inflammation and pseudomembranes compared to prior. 250 mL of donor stool was infused through the colonoscope into the cecum. The following day after the second FMT, the patient began having formed stool and improved leukocytosis. She was discharged from the hospital 3 days after the second FMT with normal stool consistency and normal WBC count.

DISCUSSION:

There have been no clear data regarding directing severe rCDI treatment with regards to the length of time in between FMTs. Clinicians should be aware that patients may need multiple FMTs to treat rCDI. A shorter duration in between FMTs may rapidly improve severe rCDI, reduce the duration of hospitalization, and improve outcomes.
1633 Extensive Colonic Ischemia Due to Sumatriptan: An Unusual Adverse Effect
Authors: Mazumder Mohammed , Thorpe Candy , Horenstein Frances , Mazumder Jubaida
Published: October 2019

INTRODUCTION:

Ischemic colitis (IC) is attributed to variety of etiologies including hypo-perforation due to dehydration, sepsis; thrombosis and embolic/thrombotic arterial occlusion. Pharmacological agents like 5Hydroxytryptamine1 (5HT 1) receptor agonists including Sumatriptan, widely used for refractory headaches, have also been known to be a cause of IC in rare circumstances. There are approximately 12 cases of IC reported which are related to 5 HT1 use. We are reporting a case of IC, which is likely related to long-term use of Sumatriptan.

CASE DESCRIPTION/METHODS:

A 39-year-old female with no significant past medical history was admitted to medical floor due to diffuse crampy abdominal pain and bloody diarrhea. Laboratory workup shows WBC 11500 cell/ml and negative IBD serology. CT of the abdomen and pelvis revealed pan-colitis. Stool culture and C. Difficile DNA were negative. Colonoscopy performed during admission revealed severe colitis involving entire colon except the rectum and distal sigmoid colon, biopsy featured ischemic colitis. A mesenteric Doppler ultrasound was ordered which was not conclusive, subsequently CTA performed which showed no mesenteric vascular stenosis. She was not on oral contraceptive pills and through careful questioning she mentioned that she had been taking Sumatriptan for a while. Due to the presumed association between Sumatriptan and IC, Sumatriptan was discontinued. She was emperically started on mesalamine and steroid, which were discontinued. Her symptoms improved with conservative management. A repeat colonoscopy in a few months after her hospital discharge did not show any colitis or ileitis; random colonic biopsies were unremarkable while she was off sumatriptan.

DISCUSSION:

Although rare, Sumatriptan use can be associated with IC, therefore we should be vigilant in reviewing medication lists in situations where there is no obvious etiology. Incidence of drug-related ischemia might be more than reported. It is imperative to counsel about meidcation adverse effect and reporting adverse effects.
1689 Managing Bouveret Syndrome in the Setting of Complex Foregut Anatomy: Impossible Is Nothing!
Authors: Hughes Michelle L. , Cheong Janice , Enslin Sarah , Kaul Vivek , Kothari Truptesh , Kothari Shivangi
Published: October 2019

INTRODUCTION:

Bouveret syndrome is a rare complication of cholelithiasis. Traditional treatment has been surgical, but endoscopic therapy has emerged as an attractive option, especially in surgically unfit patients.

CASE DESCRIPTION/METHODS:

An 80-year-old female with history of coronary artery disease/CABG on Clopidogrel and COPD on home oxygen presented with severe right upper-quadrant abdominal pain and nausea for 3 days. WBC was 14,400 μ/L, afebrile, with stable vital signs. Liver tests were normal. Abdominal ultrasound showed cholelithiasis and an obstructive calcified shadow at the pylorus. CT abdomen revealed a dilated stomach, gallstones and a 3 cm gallstone in the duodenal bulb with entero-biliary fistula. Endoscopic treatment of Bouveret was planned. At endoscopy, an unexpected high-grade mid-esophageal stricture prevented passage of standard and ultra-thin gastroscopes. A 8 mm balloon dilation was performed causing a modest-sized mucosal rent. An ultrathin gastroscope (5.9 mm) was then passed through the esophageal stricture and to the duodenum. A large pigmented gallstone was encountered in the duodenal bulb with luminal occlusion. Saline solution was infused and electrohydraulic lithotripsy (EHL) was performed at escalating settings up to 100W/ 20 shots per activation. The stone was ultimately fragmented and luminal patency restored. An ulcer with a visible vessel was seen at anterior wall of duodenal bulb; brisk bleeding was noted and hemostasis was achieved with epinephrine spray and 18 W cautery using pediatric snare tip, due to limitations of a 2.0 mm endoscope channel. The entero-biliary fistula was cannulated with the ultrathin endoscope and an additional large pigmented stone was seen in the gallbladder. This was left undisturbed. The patient had an uneventful recovery and was discharged home on regular diet after 2 days.

DISCUSSION:

Endoscopic management of Bouveret syndrome is an effective intervention and should be preferred in patients with severe comorbidities. This case demonstrates how anatomic and device related challenges were overcome using an ultrathin gastroscope to manage Bouveret syndrome and luminal bleeding. An ultrathin endoscope successfully permitted performance of EHL, evaluation of cholecystoduodenal fistula and hemostasis to save the day in this complex clinical scenario.

Watch the video: http://bit.ly/2XSIcxr.
1705 Esophageal Food Impaction: Novel Use of Water Flushes and Esophageal Overtube as a Safety Indicator and Facilitator to Push Food Bolus Into the Stomach
Authors: Shao Paul , Grewal Jasleen , Leung Felix
Published: October 2019

INTRODUCTION:

Esophageal food impaction requires urgent intervention. A food bolus is removed endoscopically by extraction or push into the stomach. Due to risks of perforation, controversy exists between when to extract verses to push. There are no clear guidelines on when it is safe to push on a food bolus; endoscopists rely on their subjective experiences and judgments. We present a case of the novel use of water flushes and an esophageal overtube to determine the safety of pushing on a food bolus to facilitate its passage into the stomach.

CASE DESCRIPTION/METHODS:

A 69 year-old man presented to the ED 12 hours after ingesting a piece of steak and a sensation of food stuck in his throat. The patient underwent esophagogastroduodenoscopy (EGD), which showed a large meat bolus firmly fixed in the upper esophagus. An overtube was placed to protect the airway. Extraction was attempted in piecemeal fashion. Because the food bolus was soft, only tiny pieces were retrieved with each attempt. We used water flushes to help determine when it would be safe to push the bolus. Initially, water retained proximal to the bolus (refluxed back into the overtube), suggesting that there was a complete luminal obstruction and that pushing would be ineffective and unsafe. Later, after more of the bolus was extracted, water passed beyond the bolus distally (no longer refluxed back into the overtube), indicating partial luminal obstruction and that it may be safe to push the food bolus. With a gentle push, the food bolus passed into the stomach easily.

DISCUSSION:

In esophageal food impaction, there are no clear guidelines on when it is safe to attempt the push method. We demonstrate a novel way of using water flushes and esophageal overtube to help objectively decide when it might be safe to push the food bolus. If water is retained and refluxed into the overtube, there may be a complete luminal obstruction and push is not recommended. If water does not accumulate or refluxed into the overtube, there is an opening in the lumen allowing the water travel distal to the bolus and pushing the food bolus may be considered. The use of water flushes and an esophageal overtube is safe, easy and cost-effective. It may serve as an additional safety indicator to help decide when to push the food bolus. In addition, water may moisturize the food bolus and help loosen the impaction to facilitate its passage into the stomach.
1721 Black Esophagus: A Case of Acute Esophageal Necrosis
Authors: Aujla Amreet K. , Elkhattib Ismail , Siddappa Pradeep , Pratt Perry , Bath Roopjeet , Hoffman Martin
Published: October 2019

INTRODUCTION:

Acute esophageal necrosis (AEN) is a rare clinical entity characterized by diffuse, circumferential, black-appearing distal esophageal mucosa on EGD typically limited to the gastroesophageal junction. In this case, we discuss AEN in a chronically ill female precipitated by an acute low perfusion state in the setting of her preexisting vasculopathy.

CASE DESCRIPTION/METHODS:

A 76-year-old female with past medical history of severe coronary artery disease, high-grade distal aortic stenosis, gastroesophageal reflux disease, history of ischemic colitis presents with two-day history of melena. Patient initially presented at an outside hospital for symptomatic anemia and was transfused packed red blood cells. She was transferred to our institution and was found to have a systolic blood pressure in the 80s. Physical exam was notable for pallor and a delayed capillary refill time. Labs revealed a hemoglobin of 10.8 g/dL, white blood count of 17 uL, procalcitonin of 1.8 ng/mL, creatinine of 1.2 mg/dL, INR of 2.7, and albumin of 2.5 g/dL. CT of the chest and abdomen revealed a right lower lobe lung consolidation and a very decompressed IVC concerning for a low volume state. Patient was adequately fluid resuscitated, kept NPO and was placed on a pantoprazole (PPI) infusion. An EGD was performed which revealed diffuse severe mucosal changes characterized by ulceration with necrotizing black mucosa in the lower third of the esophagus, and non-bleeding cratered and superficial duodenal ulcers. One week later, a repeat EGD demonstrated significant esophageal mucosal healing with esophagitis and distal esophageal ulcerations. Esophageal biopsies revealed denuded submucosa, marked acute inflammation with negative HSV, CMV and fungal cultures. Given the significant improvement in symptoms and findings, her diet was advanced. She was discharged on oral PPI and sucralfate with a plan for repeat EGD in three months.

DISCUSSION:

The incidence of AEN ranges from 0.2% to 0.28%, however, true prevalence is underestimated given the transient nature of the insult and early tissue healing. Distal esophagus and duodenal injury are common given their similar supply from the celiac artery. This case highlights a rare disease entity with increasing prevalence owing to the increased number of comorbid conditions attributed to the disease process. It emphasizes the potential causes of the disease and timely diagnosis warranting physicians to have an understanding and awareness on potentially fatal but reversible clinical syndrome.
1757 Melanoma Metastatic to the Esophagus
Authors: Yarze Joseph C.
Published: October 2019

INTRODUCTION:

To describe a case of melanoma metastatic to the esophagus.

CASE DESCRIPTION/METHODS:

A 65 yo male with a prior history of hypertension and melanoma of the scalp treated with MOHS in 2011 presented in 1/19 for direct-access EGD to evaluate chronic reflux symptoms (which were responsive, but PPI-dependent). The EGD was normal aside from revealing an 8 mm, deeply pigmented, raised nodule in the upper esophagus at 30 cm from the incisors (Figure 1). Biopsies revealed malignant melanoma (lesional cells positive for SOX10 and MiTF; negative for MN116). The patient was referred to medical oncology. PET-CT staging of the chest and abdomen were negative and brain MRI was normal. After multidisciplinary consideration, the patient underwent esophageal EUS and ESD of the esophageal lesion. The resected melanoma lesion was confined to the mucosa. After further consideration, the patient opted to undergo adjuvant therapy with nivolimumab.

DISCUSSION:

While malignant melanoma has a known propensity to metastasize to the GI tract, esophageal metastases are uncommon. Our patient was found to have an asymptomatic esophageal metastatic lesion, which was found incidentally when he underwent EGD to evaluate chronic reflux symptoms. He was successfully treated with ESD of the localized metastatic lesion followed by adjuvant nivolimumab therapy.