bluuebunny/crossref_metadata_2025 huggingface dataset:
2105 Below the Belt: Unsual Site of Aortitis in Crohn's Remission
Authors: Mishra Kajali , Naffouj Sandra , Kaur Nirmal
Published: October 2019

INTRODUCTION:

Aortitis is inflammation of the vessel wall that results in luminal narrowing or vessel strictures. It can involve any part of the aorta. In patients with Crohn’s, the reported sites of aortic inflammation are aortic valve leaflets and aortic root, which can result in aortic insufficiency and aneurysmal dilation.

CASE DESCRIPTION/METHODS:

A 61-year-old female with stable Crohn’s disease presented with epigastric pain, non-bilious non-bloody emesis, and diarrhea. She discontinued Mesalamine 8 years ago. Laboratory studies revealed leukocytosis (12K) and erythrocyte sedimentation rate of 12. Computed Tomography showed fat deposition in the terminal ileum and cecum, mesenteric edema with new wall thickening and fat stranding of the abdominal aorta (AA) and left common iliac artery (CIA). CT angiography (CTA) revealed a 6 mm soft tissue ring around the infra-renal AA with moderate stenosis and extension into the left CIA, compatible with aortitis. Aortic biopsy was not performed given no signs of systemic vasculitis or giant cell arteritis. Infectious etiology was suspected; blood cultures, urinalysis, stool PCR, Clostridium-difficile, HIV, Syphilis, Hepatitis, QuantiFERON, Histoplasmosis, Blastomycosis, Yersinia-Enterocolitica PCR, Cryptococcal antigen, serologies for Lyme disease, Rickettsia, Coxiella, Brucella, Bartonella, and Chlamydia were all negative. Transthoracic echocardiogram showed no evidence of endocarditis. Rheumatologic workup was negative (ANA, RF, ANCAs, CRP, IgG subclasses). Systemic antibiotics were started given concern for infection but the patient did not clinically improve. Given lack of improvement on antibiotics, methylprednisolone was initiated. Repeat CTA showed persistent inflammation. Adalimumab was started with significant symptomatic improvement. At 6 month follow up the patient was asymptomatic and repeat CTA showed no evidence of inflammation.

DISCUSSION:

We present a rare case of infra-renal aortitis in a patient with stable Crohn’s disease. There is only one reported case of abdominal aortitis in a patient with Crohn’s, but that patient had severe fulminant disease. Our patient with Crohn’s in remission had nonspecific gastrointestinal symptoms (epigastric pain, emesis, diarrhea), and was found to have infra-renal aortitis. Aortitis carries a high risk of aortic rupture and thrombosis of small vessels. Early recognition is crucial, as immunosuppressive agents can be used to reduce the risk of life threatening clinical complications.
2112 Delayed Onset of Inflammatory Bowel Disease During Treatment With Secukinumab
Authors: Nallapeta Naren S. , Picano John D. , Bou-Abdallah Jad
Published: October 2019

INTRODUCTION:

Secukinumab is an interleukin-17 inhibitor commonly used for treating ankylosing spondylitis (AS). Recent reports described new onset inflammatory bowel disease (IBD) in patients treated with Secukinumab. To our knowledge, this is the first case report to describe a delayed presentation of new onset IBD in a patient 14 months after beginning treatment with Secukinumab.

CASE DESCRIPTION/METHODS:

A 68 year old male presented with 2-3 bloody bowel movements per day, fever and 20 lbs of unintentional weight loss for six weeks. Past history was significant for AS treated with Secukinumab for 14 months after failing therapy with other biologics (Etanercept, Adalimumab and Infliximab). A screening colonoscopy 3 months prior to presentation revealed no evidence of colitis. Labs were notable for an elevated WBC 13.2 and ESR 74, stool testing was negative for Clostridium difficile. A flexible sigmoidoscopy showed erythematous mucosa beginning in the rectum. Multiple deep ulcerations were noted beginning at 30 cm (Figure 1) and biopsies showed a diffuse pattern of brisk chronic active colitis. Secukinumab was discontinued. Methylprednisolone and mesalamine were begun and resulted in significant improvement in his symptoms. The patient presented again with similar symptoms one month later. Repeat flexible sigmoidoscopy showed partial healing. Biopsies demonstrated chronic active colitis consistent with IBD. A repeat flexible sigmoidoscopy performed 6 later showed complete mucosal healing (Figure 2).

DISCUSSION:

We present the first case report of delayed onset IBD in a patient with AS treated with Secukinumab. Previously reports demonstrated a rapid onset of presentation, usually either after first infusion or within a few weeks of treatment (JCC, 2018, 1131-1133). Interestingly, our patient had a routine screening colonoscopy 3 months prior to symptom onset which showed no evidence of IBD. The pathogenesis of new onset IBD in patients treated with Secukinumab is not clear. IL-17A is known to be pro-inflammatory in IBD but certain mouse models demonstrated IL-17A to be protective in T cell mediated colitis, and IL-17A-deficient mice developed rapid weight loss and severe colitis (Nat Immunol. 2009;10:603–9). This case suggests that new onset IBD in patients taking Secukinumab may present many months after initiation of therapy. Clinical suspicion should remain in patients with symptoms suggestive of IBD many months after starting, and even tolerating, Secukinumab.
2119 Acute Post-Operative Drainage With a Lumen-Apposing Metal Stent (LAMS)
Authors: McDonald Nicholas M. , Storm Andrew C.
Published: October 2019

INTRODUCTION:

Peripancreatic fluid collections may occur following pancreatic resection and are traditionally managed by percutaneous surgical drains. Endoscopic management of these peripancreatic fluid collections is increasingly utilized and there is growing experience in this realm.

CASE DESCRIPTION/METHODS:

A 54-year-old woman with a history of resectable adenocarcinoma of the pancreatic tail (T1a) who received FOLFIRINOX neoadjuvant therapy and was transitioned to Gemcitabine/Abraxane, presented for surgical management. She initially underwent laparoscopic, hand-assisted distal pancreatectomy and splenectomy. She tolerated surgery with no immediate complications. On postoperative day #4, she developed moderate abdominal pain. Computed tomography (CT) demonstrated an irregularly-shaped, hypodense fluid collection measuring 7.5 × 6.5 × 8.3 cm about the pancreatic tail, concerning for pancreatic duct leak. The decision was made to perform endoscopic drainage under endoscopic ultrasound guidance. On postoperative day 6, EUS demonstrated a 7 × 4 cm septated collection in the postoperative bed in the region of the distal pancreas (Figure A). The acute collection had not yet become walled off based on CT and EUS. The common wall between the stomach and cyst was interrogated utilizing color Doppler and an ideal puncture sight was determined. An electrocautery enhanced lumen apposing metal stent (LAMS) was advanced into the cyst and a 10 × 10 mm LAMS was placed with flanges in close approximation to the fluid collection and stomach wall through cystgastrostomy (Figure B). An additional 7 Fr by 4 cm soft double pigtail stent was then placed coaxial to the LAMS to maintain patency. At follow-up, two weeks later, her abdominal symptoms had resolved. Her interval scan demonstrated a significantly decreased pancreatic tail collection and transgastric LAMS. At postoperative day 10, cross sectional imaging demonstrated complete resolution of her fluid collection, and endoscopy was performed with uneventful LAMS removal (Figure C).

DISCUSSION:

This case demonstrates a patient with an acute postoperative peripancreatic fluid collection after distal pancreatectomy which was successfully treated six days postoperatively with transgastric cystgastrostomy using a LAMS. While traditional management in the acute postoperative setting has been percutaneous drain placement, further study is needed to evaluate the safety and efficacy of minimally invasive, endoscopic methods of postoperative drainage.
2120 A Rare Case of Primary Adrenal Leiomyosarcoma Diagnosed via EUS-Guided Fine-Needle Biopsy
Authors: Gajula Prianka , Dacha Sunil
Published: October 2019

INTRODUCTION:

Leiomyosarcoma is a rare tumor that arises from smooth muscle wall. It is well known to be an aggressive tumor usually found in the uterus or abdominal cavity. However, primary adrenal leiomyosarcoma (PAL) is rarely seen. Here, we present a case of PAL diagnosed by endoscopic ultrasound-guided fine needle biopsy (EUS-FNB).

CASE DESCRIPTION/METHODS:

A 69-year-old female presented with a 3-week history of cramping LUQ abdominal pain and left flank pain. Medical history was remarkable for seasonal allergies and adult Still’s disease at the time of diagnosis. A CT and MRI of the abdomen with renal protocol was performed, which revealed a large, heterogeneous mass in the retroperitoneum and in continuity with the posterior wall of the gastric fundus and measuring 7.3 × 5.1 cm. This mass displaced the adrenal gland medially and the kidney posteriorly. The patient underwent EUS guided biopsy of the mass. On endoscopic examination, there was extrinsic compression in the fundus and posterior wall of the proximal body of the stomach. Endosonographic examination confirmed this compression to be due to a retroperitoneal mass. This measured 71 mm × 48 mm in cross-section. It was heterogeneous in appearance and abutted the posterior wall of the stomach. The mass lesion appeared to originate from and compress over the left adrenal gland. Cytopathologic evaluation was consistent with a spindle cell carcinoma, suggesting a leiomyosarcoma. Immunostains showed the spindle cells positive for SMA, but negative for c-Kit, DOG-1, and S100. Shortly thereafter, a pancreatectomy, splenectomy with left nephrectomy and adrenalectomy were performed concurrently by surgical oncology and urology. Post-surgical course was uncomplicated. Final pathology was suggestive of an 8 cm Leiomyosarcoma of the left adrenal gland with no vascular invasion and margins free of tumor.

DISCUSSION:

Primary adrenal leiomyosarcoma is exceedingly rare. There are only approximately 40 reported cases. Literature review reveals that the majority of these cases were diagnosed after laparoscopic or open surgical resection. There is only one prior reported case of PAL diagnosed by EUS guided tissue sampling. This case demonstrates the well-documented safety and efficacy of EUS-FNB for diagnosing mass lesions when cross-sectional imaging is equivocal and performing biopsies of these lesions. GI tract provides a unique window for performing high-quality imaging by EUS guided examination and simultaneously performing transmural interventions.
2122 Novel Use of EndoRotor® Device to Clear Large Obscuring Clot in Patient With Upper Gastrointestinal Bleed
Authors: Gubatan John , Kwo Paul , Hwang Joo Ha
Published: October 2019

INTRODUCTION:

Significant clot burden limits visibility and prevents finding intervenable lesions for hemostasis. Endoscopic tools and promotility agents are available to disrupt clots and increase visibility with varying degrees of success. The EndoRotor® device is a non-thermal, automated endoscopic resection system designed to remove benign mucosal tissue throughout the gastrointestinal tract. Here, we present a challenging case where standard endoscopic techniques failed to clear a large obscuring gastric clot and how novel application of the EndoRotor® allowed successful localization of the culprit lesion.

CASE DESCRIPTION/METHODS:

A 79 year old woman with a history of end stage renal disease and liver fibrosis presented with coffee ground emesis and melena. On admission, initial labs were notable for Hgb 9.7, Plts 129, INR 1.1. Patient was treated with IV pantoprazole and octreotide. EGD was notable for nonbleeding esophageal varices and a moderate size blood clot in the lesser curvature and fundus of stomach obscuring visualization and the procedure was terminated. Patient continued to pass melena with Hgb drop to 5.8 requiring 3 units pRBC and metoclopramide was added to her regimen to try to clear the large clot. Repeat EGD revealed an interval increase in size of blood clot. Despite irrigation and suction, area could not be cleared. Use of cold snare or Roth net removal were not feasible due to clot size and use of BioVac® was ineffective. A repeat EGD was performed the following day using the EndoRotor®. The combination of the EndoRotor device’s rotating cold blade and suctioning enabled the large clot to be liquefied. Fibrous tissue intermittently clogged the EndoRotor® suction channel but was easily cleared with flushing. After about 30 minutes, the large obstructing clot was completely cleared revealing a bezoar. The patient was kept NPO and continued on IV metoclopramide for 48 hours to clear the bezoar. An EGD was then repeated which revealed a 5 mm cratered ulcer in the posterior gastric wall with a nonbleeding visible vessel. Bipolar probe was applied successfully for hemostasis.

DISCUSSION:

Our case illustrates the challenges associated with a large clot obscuring visualization. Standard use of promotility agents with supportive care were not successful as the patient continued to intermittently bleed increasing the clot size . Our case is the first reported application of the EndoRotor® to safely to clear large blood clots in upper GI bleeding as an adjunct to our standard therapies.
2126 Endoscopic Ultrasound-Guided Splenic Mass Biopsy. an Accessible Technique for Differential Diagnosis of Lymphoma
Authors: Leon-Jarrin Daniela , Fahmawi Yazan , Kumar Manoj , Mizrahi Meir
Published: October 2019

INTRODUCTION:

Traditional methods for splenic mass biopsy includesurgical or percutaneous technique, however there is an increased risk of hemorrhage, hematoma or cutaneous infection associated with these techniques. In addition, these techniques do not allow us to evaluate adjacent organs. Endoscopic ultrasound (EUS) provides a novel method for splenic mass biopsy and should be considered for such procedures. Our case highlights technique for a successful and safely done EUS guided splenic mass biopsy.

CASE DESCRIPTION/METHODS:

Case: 68-year-old female with history of non-Hodgkin lymphoma in remission, stage IIIbsquamous cell carcinoma of anus treated with chemoradiation and on surveillance referred to GI after a surveillance CT abdomen/pelvis revealed spleen enlargement with hypodensities. This was followed by PET/CT with increased uptake on anal region, spleen, stomach and supraclavicular node. Endoscopy with EUSwas performed. Biopsies were obtained from stomach and duodenum. EUS imaging showed splenic lesion. Fine Needle Biopsy was performed with 22-gauge needle with a slow pool technique. 4 needle passes were made into the mass. Specimen was sent for pathology and flow cytometry. Patient tolerated procedure without complications. Biopsy report showed evidence of B cell lymphoma on all samples with diagnosis of relapsed B cell Non-Hodgkin lymphoma.

DISCUSSION:

EUS can provide a feasible and safer technique to obtain splenic mass biopsies. This technique utilizes the proximity of gastrointestinal tract and therefore a readily accessible path to obtain splenic biopsies. Endoscopic ultrasound can also provide a safe way to evaluate adjacent organs during the work up of disease extent involvement, all in one minimally invasive procedure,reducing the amount of risks and complications associated with traditional biopsy techniques.
2131 Endoscopic Mucosal Resection of a Proximal Esophageal Pyogenic Granuloma
Authors: Estifan Elias , Patel Varun , Grossman Matthew
Published: October 2019

INTRODUCTION:

Pyogenic Granuloma (PG), also known as lobular capillary hemangioma, is usually seen as a polypoid red lesion found on the skin or the mucosal surface of the oral cavity. PG of the gastrointestinal tract is rare, in particular involving the esophagus, only 14 cases have been reported in the English literature.

CASE DESCRIPTION/METHODS:

We present an 80-year-old male who underwent endoscopy for evaluation of dysphagia and was found to have a single, red, bilobed 10 mm polyp with adherent white exudate approximately 19 cm from the incisors (Figure 1). Endoscopic ultrasound was performed with a 20 mHz miniprobe which showed the lesion contained to the mucosal layer with no muscularius propria invasion. A decision was made to perform endoscopic mucosal resection (EMR). A mixture of saline and methylene blue was injected into the submucosal plane to raise the lesion with subsequent successful mucosal hot snare resection (Figure 2). The resection defect was then approximated and closed with a hemostatic clip to prevent bleeding. Pathology of the specimen revealed small capillary vessels growing in a lobular architecture with an edematous stroma and a florid inflammatory infiltrate representing a pyogenic granuloma (Figure 3).

DISCUSSION:

EMR allows for an en bloc resection of mucosal lesions with tumor-free margins thereby providing both diagnostic and prognostic information. Comparing EMR with the novel technique of endoscopic submucosal dissection (ESD), the incidence of bleeding and perforation is much lower; making EMR the best and safest resection option for this rare hemangioma. In this case, we demonstrate that EMR is a safe technique in removing a pyogenic granuloma in the esophagus.
2143 A Unique Complication of Gastrostomy Tubes
Authors: Baloch Luqman
Published: October 2019

INTRODUCTION:

In 1979 the Gauderer-Ponsky technique was developed to allow endoscopic placement of gastrostomy tubes (G-tubes). The procedure allowed fistulation between the stomach and abdominal wall. G-tubes are often placed for enteral feeding in patients who have either an inability or insufficiency of intake by mouth. Complications of G-tubes are often seen but an overwhelmingly majority of them are minor. At times G-tubes lead to soft tissue & skin infections, colocutaneous fistulas, & visceral perforations. These more serious complications can occur up to 11-15%. Smaller complications such as dislodgement or G-tube dysfunction are far more common.

CASE DESCRIPTION/METHODS:

A 49 year-old male with a past medical history of traumatic brain injury with placement of a percutaneous endoscopic gastrostomy tube (G-tube) who presented to the ED after pulling out his G-tube. Unable to place the G-tube back at bedside, interventional radiology reinserted under fluoroscopy. After discharge he presented back to the ED with coffee ground emesis & aspiration. He was noted to have klebsiella pneumonia. Despite being appropriately treated for his pneumonia he continued to have worsening septic shock abdominal distention. CT imaging was positive for large collection of fluid, gas, & contrast filling his peritoneum. Emergent exploratory laparotomy found 6L of peritoneal fluid & a perforated fistulous tract draining into his peritoneal cavity. Meanwhile his abdominal viscera was coated with a white film. Labs & cultures confirmed peritonitis caused by klebsiella, enterococcus, & candida. He received antibiotics and antifungal therapy, required multiple washouts, & surgical correction of the perforation with a wedge gastrectomy.

DISCUSSION:

This patient developed a rare & serious complication after G-tube placement. Dislodging the G-tube in a traumatic fashion caused drainage into his peritoneum. Even though the G-tube was replaced under radiographic guidance he developed a terrible case of peritonitis. The rates of complications are statistically the same in radiographically or endoscopically placed G-tubes. This patient required surgical placement of another G-tube along with and a wedge gastrectomy. This complication of fungal peritonitis & aspiration pneumonia show us that G-tubes are not always benign. Endoscopic, surgical, and radiographic techniques may all have a different approach to ensure good outcomes but a patient’s ability to receive good G-tube care is essential in preventing long term complications.
2144 Gastric Hyperplastic Polyps Are Resistant to Treatment by Endoscopic Submucosal Dissection
Authors: Roy Justin , Loloi Justin , Moyer Matthew , Mathew Abraham
Published: October 2019

INTRODUCTION:

Hyperplastic gastric polyps represent a subset of gastric polyps that are known to have malignant potential, with 5-19% harboring focal dysplastic changes, suggesting there would be a benefit to resection. Size > 1.0 cm and pedunculated morphology have been shown as clear risk factors for malignant transformation. Current ASGE recommendations state that any hyperplastic polyp > 0.5 cm be resected. Despite these recommendations, it is unclear how successful current endoscopic techniques are in the long-term management of these polyps. In this study, we sought to better understand if endoscopic submucosal dissection (ESD) would be successful in sustained removal of hyperplastic polyps.

CASE DESCRIPTION/METHODS:

We conducted a retrospective review of all patients between 2013 and 2019 who underwent ESD at our institution. Those who underwent ESD for treatment of hyperplastic polyps were included. Both the endoscopy reports and pathology reports were analyzed for ESD procedures looking at documented complications, polyp size, and enbloc removal.

DISCUSSION:

In total, 188 underwent ESD during the time frame studied, and 9 patients met inclusion criteria. In total, 12 ESD procedures were found. On average, each patient underwent 1.6 endoscopies prior to ESD, and 4.9 total for treatment of hyperplastic polyps. When removed by ESD, the average polyp size was 37 mm (range: 15 – 80 mm), and 63.6% were able to be removed enbloc. All polyps were located in the antrum. During ESD, there was intra-procedure bleeding during 83.3% of cases. This was controlled with clips, APC, and overstitching. No patients required hospitalization or emergent surgery. Of the 12 ESD procedures documenting successful polypectomy, 8 had follow up endoscopies within 12 months, with 100% recurrence of hyperplastic polyps. The remaining 4 are awaiting or lost to follow-up. Hyperplastic polyps involving the gastric antrum need removal due to cancer risk and often blood loss. Those resistant to standard resection can be effectively removed by ESD. Although ESD safely and successfully removed polyps, our patient population with follow up suffered a 100% recurrence rate of polyps despite good margins. Thus ESD, while safe, is not successful preventing recurrence. The pathological basis for this recurrence is unclear. We conclude that large gastric polyps recur almost always even after successful removal of by ESD.
2158 Successful Endoscopic Retrograde Cholangiopancreatography in a Patient With Situs Inversus and Choledocholithiasis
Authors: Holmes Ian , Ostroff James W.
Published: October 2019

INTRODUCTION:

Situs inversus is a congenital condition that causes left-right reversal of all organs. This results in unique challenges for the endoscopist when patients with situs inversus require ERCP. Several methods have been described in the literature to optimize the chances of successful cannulation in these unique patients. We describe the case of a 75 year old woman with situs inversus who developed choledocholithiasis requiring ERCP for stone extraction. We review the clinical features of situs inversus, as well as the methods needed to obtain successful cannulation.

CASE DESCRIPTION/METHODS:

A 75 year old woman with complete situs inversus was transferred to our facility. Eight days prior to this presentation, she developed epigastric pain and emesis. She had new liver test abnormalities with ALT 277, AST 110, alkaline phosphatase 221, and total bilirubin 5.5. A CT scan showed dilation of the common bile duct to 7 mm with a 6 mm stone noted in the distal duct. Upon arrival at our facility, ERCP was performed in the left lateral position. The procedure was notable for distortion of the stomach and duodenal bulb consistent with situs inversus. A precut sphincterotomy was necessary to achieve biliary cannulation. The bile duct was noted to come off the ampulla at 1 o’clock, in mirror image from normal anatomy. A 9 mm stone was identified and removed with a basket.

DISCUSSION:

Situs inversus is an autosomal recessive congenital condition with an incidence rate of approximately 1 in 5,000 to 10,000 live births. There is no evidence that situs inversus contributes to increased gallstone formation. Currently, there are 15 cases of ERCP performed for choledocholithiasis in situs inversus patients described in the literature. Besides the obvious differences in the orientation of the stomach and duodenum, the bile duct is often noted to come off the ampulla at “1 o’clock” instead of the typical “11 o’clock.” A variety of methods have been described to address these anatomical differences, including placing the patient in the prone position, changing the side of the bed that the endoscopist stands on, setting up the ERCP suite in mirror image, and rotating the duodenoscope 180 degrees clockwise in the stomach, and then either rotating an additional 180 degrees in the second portion of the duodenum or using a rotating sphincterotome. Endoscopists should be aware of the various techniques to optimize cannulation in patients with situs inversus to maximize chances of a successful intervention.
2164 Percutaneous Transhepatic Single-Operator Cholangioscopy With Electrohydraulic Lithotripsy in the Management of Intrahepatic Stones in a Post-Orthotopic Liver Transplant Patient With Ischemic Cholangiopathy
Authors: Stadmeyer Peter , Dalvie Prasad , Hubers Jeffrey , Gopal Deepak
Published: October 2019

INTRODUCTION:

Advancements in endoscopic retrograde cholangiopancreatography (ERCP) have revolutionized the management of biliary stones. However, endoscopic management of intrahepatic stones continues to be challenging. We discuss a patient with intrahepatic stones who was treated with percutaneous transhepatic cholangioscopy with electrohydraulic lithotripsy (EHL).

CASE DESCRIPTION/METHODS:

A 68-year-old man with alcoholic cirrhosis underwent orthotopic liver transplant from a deceased after cardiac death donor. His post-transplant course was complicated by ischemic cholangiopathy, biloma development and recurrent episodes of cholangitis. He underwent placement of an external biliary drain for management of his biloma. An MRCP demonstrated persistent biloma as well as mural irregularities within the intrahepatic ducts concerning for intrahepatic stones. Due to recurrent cholangitis, a combined IR (interventional radiology)-biliary endoscopic procedure was undertaken. IR performed a percutaneous cholangiogram (PTC) which demonstrated multiple filling defects in the left hepatic ducts consistent with stones. A 5 French Fogarty balloon was advanced and inflated with multiple sweeps in an attempt to extract the filling defects into the common bile duct. Antegrade cholangioscopy was then performed with single-operator cholangioscope (SpyGlass 2™) passed through a 14 French PTC sheath. Using the cholangioscope we were able to visualize impacted stones within the left intrahepatic system and treat them utilizing EHL with a catheter setting of 40-50 Watts for stone fragmentation and suction. The single-operator cholangioscope was then directed at the common bile duct and two large retained stones were treated with EHL. Subsequently, a traditional ERCP was performed which noted filling defects within the common bile duct. Balloon sphincteroplasty was performed and using an 8.5-11.5 mm balloon catheter, CBD exploration and balloon sweeps were performed with extraction of 2 large stones and sludge. Occlusion cholangiogram at the completion of the procedure revealed no further stones and patent anastomosis. To allow adequate biliary drainage, a retrievable 10 mm × 60 mm SEMS covered metal biliary stent and a new 14 French external biliary drain was placed. The biliary stent was removed 3 months later with ERCP demonstrating no recurrent stones.

DISCUSSION:

Complex intrahepatic lithiasis may be successfully managed with a multi-disciplinary collaborative approach between Interventional Radiology and biliary endoscopists.
2167 Endoscopic Closure of a Duodeno-Pleural Fistula Secondary to Transarterial Chemoembolization
Authors: Natov Peter S. , Kesar Sukeerti , Yacavone Robert F.
Published: October 2019

INTRODUCTION:

Transarterial chemoembolization (TACE) is an increasingly performed treatment for advanced stage hepatocellular carcinoma (HCC) not amenable to surgical intervention. Though effective, it is not without risk. Notable complications include post-embolization syndrome, decompensation of cirrhosis, acute cholecystitis, and acute pancreatitis, and rarely hepatic artery injury, liver abscess, duodenal perforation, and bile duct injury. Fistula formation appears to be among the rarest of complications. We describe the presentation of a duodeno-pleural fistula as a complication of TACE and its endoscopic closure with an over-the-scope clip (OTSC).

CASE DESCRIPTION/METHODS:

A 49-year-old woman with a history of chronic hepatitis B cirrhosis and HCC presented to the emergency room with right-sided chest pain. She was diagnosed with HCC 16 years ago in China and underwent partial hepatectomy and chemotherapy. Two years prior to current presentation, MRI demonstrated a 2.0 × 2.7 × 3.3 cm liver lesion consistent with recurrent HCC. TACE was performed. She subsequently reported abdominal pain. Endoscopy discovered a duodenal ulcer, and imaging noted a developing phlegmon and free air. Management with bowel rest and parenteral nutrition led to clinical improvement without the need for surgery. On this presentation, she described new onset pleuritic chest pain and dyspnea. Imaging revealed a large loculated right pleural effusion with gas foci and visible extraluminal enteric contrast surrounding the duodenal bulb, suggestive of an empyema secondary to a duodeno-pleural fistula (Figure 1). Pleural fluid analysis showed a pH < 6.8, high amylase and lipase levels, and cultures of multiple enteric organisms. Fistula closure was attempted endoscopically. A 4 mm opening was found in the duodenal bulb (Figure 2). The mucosa was denuded with argon beam plasma coagulation and an 11/6t OTSC successfully closed the defect (Figure 3a,b). Extravasated contrast was not seen on imaging two days later.

DISCUSSION:

Endoscopic interventions for enteric fistula closure include suturing, stents, and clips. The OTSC is increasingly recognized as a minimally invasive technique for fistula closure, with strong immediate technical success rates and variable long-term clinical success depending on location. To our knowledge, we demonstrated the first endoscopic closure of a duodeno-pleural fistula. This case supports the role of endoscopic closure with OTSC for enteric fistulae in the non-surgical candidate.
2175 Endoscopic Salvage Repair: Complicated Gastric Sleeve Leak
Authors: Fleming Harrison , Brazeau Michael , Cho Ryan , Magulick John
Published: October 2019

INTRODUCTION:

Gastric leaks following laparoscopic sleeve gastrectomy (LSG) are a feared complication, occurring in 2.4 % of cases in the proximal portion ( >90%). LSG is more prone to a leak due to a long staple line and high intraluminal pressure, sealed between an intact pylorus and lower esophageal sphincter and less likely to close spontaneously. There are no standardized guidelines for management of this or other forms of anastomotic leaks. We present a case that failed to respond to initial attempt to close with a luminal stenting, which led to multiple techniques to include endoscopic vacuum therapy (EVT), pneumatic dilation of the sleeve, and pylori Botox injection that ultimately achieved success.

CASE DESCRIPTION/METHODS:

51 year old female with a recent history of laparoscopic sleeve gastrectomy complicated by a proximal leak detected 4 weeks post op. She initially underwent endoscopic closure with an Ovesco placement over the defect of the sleeve leak and stent placement across the sleeve. UGI immediately following the procedure revealed no leak. Subsequent imaging two weeks following the procedure revealed a leak, requiring the stent removal. The endoscopic exam revealed a large proximal sleeve defect leading to a large purulent cavity (3 × 4 cm) with multiple sinus openings. She underwent endoscopic vacuum therapy (14 sessions) every 3-4 days, leading to the complete sealing of the cavity and reduction of the cavity. There was a 1 × 1 cm persistent sealed cavity with diffuse granulation tissue, requiring a placement of a double pigtail stent. After functional stenosis was noted under fluoroscopy, not allowing contrast to freely flow downstream, Botox injection of the pylorus and pneumatic dilation of the sleeve (to 30 mm, 3 sessions) were performed, to relieve the pressure gradient. UGI series confirmed the completely sealed nature of the cavity and smooth contrast flow distally to the small intestine. Pigtail stent was left indefinitely to allow natural healing.

DISCUSSION:

Multiple endoscopic techniques have been implemented to close LSG leaks. The new paradigm has focused on optimizing pressure gradients to allow internal drainage with closure of the cavity by secondary intention. Our case described an initial failed closure that ultimately achieved success with a variety of techniques to include internal drain placement and Botox and dilation. This subject would benefit from further study to determine optimal initial or stepwise approach.
2178 What You See Is Not What You Get: EUS Underestimation of Gastric Cardia Mass Size and Shape
Authors: Bill Katherine , Chaar Abdelkader , Barawi Mohammed
Published: October 2019

INTRODUCTION:

A 67-year-old-male with history of dysphagia was found to have a subepithelial mass in the gastric cardia. It was located anterolaterally along the greater curvature and had normal overlying mucosa. Endoscopic ultrasound demonstrated a 17 mm hypoechoic homogenous lesion arising from the muscularis propria without malignant features (Figure 1). It was most consistent with a leiomyoma. After discussion of the findings and management options, our patient elected to proceed with endoscopic resection.

CASE DESCRIPTION/METHODS:

A single-channel endoscope identified the lesion on retroflexion. After submucosal injection of 0.9% normal saline, methylene blue, and epinephrine, a transverse incision was made in the midsection of the bulging mass, exposing the submucosa. Repeated injections lifted the submucosa for dissection using a T-type hybrid knife. An IT-2 knife (Olympus®) was used to cut the submucosa in a circumferential fashion around the tumor. It was bilobar in appearance (Figure 2) and significantly larger than seen on EUS. All bleeding vessels were cauterized, and a large snare was used to perform en bloc resection of the tumor. We used a transverse midline incision to facilitate resection while minimizing disruption of the overlying mucosa. No mucosa was excised, and the incision was easily approximated for closure using multiple endoclips. The tumor was pale in appearance with an intact capsule. It measured 25 mm at its greatest diameter, which was 8 mm larger than EUS measurement. Histologic examination revealed bland spindle cell proliferation (Figure 3). Immunohistochemical staining was positive for actin and desmin and negative for CD117 and CD34, features consistent with leiomyoma.

DISCUSSION:

Endoscopic surgery is rapidly advancing, providing safe and feasible alternatives to more invasive therapies. We describe successful endoscopic full-thickness resection (EFTR) of a gastric cardia mass whose size and shape were significantly underestimated on pre-operative EUS. We have encountered this in prior cases, most notably lesions originating in the third and fourth gastric layers. Resection of our patient's gastric cardia tumor made this discrepancy particularly challenging, and it is a pitfall of EUS that even the most experienced endosonographers must be cognizant of.
2181 Gallbladder Irrigation via Cholecystostomy Tube as a Novel Technique for Improving EUS-Guidance During Placement of Lumen-Apposing Metal Stent (LAMS) for Cholecystoduodenostomy
Authors: Cummings Donelle , Kwak Nathan , Joseph-Talreja Mairin , Grossman Evan B. , Cheung Derrick
Published: October 2019

INTRODUCTION:

Cholecystectomy is the preferred treatment of acute cholecystitis, but it may be relatively contraindicated in patients with medical comorbidities or advanced age. Non-surgical approaches include percutaneous transhepatic cholecystostomy tube and endosonographic stent placement. Adequate endosonographic imaging of the gallbladder is essential for correct stent deployment.

CASE DESCRIPTION/METHODS:

A 55-year-old male was admitted for endoscopic cholecystoduodenostomy for palliation of chronic cholecystitis. He had prior admissions for cholecystitis and choledocholithiasis with cholangitis with prior ERCPs requiring sphincterotomy, sphincteroplasty, stone removal and common bile duct stent placement. He was a poor candidate for cholecystectomy due to multiple medical comorbidities and chronic anticoagulation and was referred for endoscopic therapy. The patient was brought to the endoscopy suite and placed under general anesthesia. The Olympus linear echoendoscope was passed to the second portion of the duodenum. The gallbladder was collapsed due to prior patent sphincterotomy and sphincteroplasty. With IR assistance, the gallbladder was irrigated with normal saline boluses of to a volume of 600 mL. Due to the patent sphincterotomy, the gallbladder would collapse requiring additional irrigation. Maximal size of the gallbladder 30 mm in the long axis and 20 mm in the short axis. The duodenal wall and the gallbladder were punctured under endosonographic guidance using the hot AXIOS electrocautery-enhanced delivery system. A stoma was created and a 15 × 10 mm AXIOS stent was placed with flanges in close approximation to the gallbladder and duodenal wall through the cholecystoduodenostomy. The echoendoscope was then withdrawn. Next, a solution of normal saline and methylene blue was injected through the percutaneous cholecystostomy tube and this solution was seen to flow from the duodenal portion of the AXIOS stent on endoscopic views, confirming adequate location of the AXIOS stent in the gallbladder and duodenum.

DISCUSSION:

The patient did well in the immediate post-procedural period. Six days post-procedure, he was noted to have melena in the setting of supratherapeutic INR and aPTT. Repeat upper endoscopy showed no evidence of bleeding. The AXIOS stent appeared normal on endoscopic views. Due to the difficulty of stent placement and palliative intent, we left the AXIOS stent in situ. The patient is currently asymptomatic and was referred to IR for removal of percutaneous cholecystostomy tube.
2193 Role of Endoscopy in Bouveret Syndrome
Authors: Saleem Sheikh A. , Arif Muhammad Osman
Published: October 2019

INTRODUCTION:

Biliodigestive fistula is a rare complication of cholelithiasis which can lead to gallstone ileus. The gallstone after passing into GI tract is eliminated in 85 % of the cases through the feces or vomitus. However in 15 % of the cases it gets entrapped in the GI tract most commonly in the terminal ileum. We describe a case of an elderly patient who presented with Bouveret syndrome secondary to impaction of the biliary calculus in the first part of duodenum.

CASE DESCRIPTION/METHODS:

A 91 yo M presented to the hospital with one week history of nausea, vomiting and abdominal pain. He was noted to have right upper quadrant abdominal tenderness. Liver function tests were unremarkable. CT abdomen with oral contrast showed findings concerning for gastric outlet obstruction secondary to large lamellated gallstone along with a choledochoduodenal fistula. An upper GI endoscopy was done which showed a large immobile gallstone obstructing the first part of duodenum. An attempt to remove the stone endoscopically by various techniques including mechanical lithotripsy and net extraction was unsuccessful. A 7 cm gallstone partially contained in the gallbladder and extending to the duodenum was then successfully removed by open partial cholecystectomy with duodenal extraction followed by choledochoduodenal fistula repair. Patient recovered well without any complications after the surgery.

DISCUSSION:

Gallstone impaction in the duodenum and pylorus is extremely rare and can lead to gastric outlet obstruction, a condition known as Bouveret syndrome. Bouveret syndrome needs to be managed in a timely fashion. Clinically patients with this condition present with nausea, vomiting and abdominal pain. History of recent bouts of jaundice and biliary colic is seen in up to 70% of the patients. Rarely patients can present with hematemesis secondary to duodenal or celiac artery erosion. CT abdomen with contrast is the imaging of choice. Medium sized mobile stone in the duodenum can be successfully managed endoscopically by lithotripsy or net extraction. However when there is an immobile large calculus, endoscopy often fails and surgical extraction of the stone needs to be done to relieve the obstruction. Nevertheless considering the higher mortality associated with surgery, endoscopic removal of the calculus should be attempted first.
2203 Rare Presentation of a Mast Cell Neoplasm as Liver Fibrosis
Authors: Hayat Maham , Corredine Thomas J. , Hassan Ayesha , Kanagala Rajesh
Published: October 2019

INTRODUCTION:

Primary myelofibrosis (PMF) is a chronic myeloproliferative disorder characterized by bone marrow fibrosis and extramedullary hematopoiesis mainly involving the liver and spleen. Clinical manifestations of the disease include severe anemia, marked hepatosplenomegaly, constitutional symptoms, cachexia, bone pain, pruritus, thrombosis, and bleeding. Super imposed mast cell neoplasm, in a patient with myelofibrosis is rare. Ascites and liver enzyme derangement as the only presenting symptom of these hematological malignancies, is seldom seen.

CASE DESCRIPTION/METHODS:

54-year-old female, with what was originally thought to be newly diagnosed, decompensated cirrhosis, who was admitted to the hospital with worsening dyspnea and abdominal pain. The patient was suspected to be septic, and admitted to the MICU. Biochemical work up revealed a total bilirubin of 6.5, AST 65, ALT 32, INR 1.3, WBC 28k and platelet count of 12,000. However, during her hospital stay she continued to have worsening of jaundice and liver enzyme derangement, thus the hepatology service was consulted. The patient’s labs were consistent with alcoholic liver disease, but the patient vehemently denied heavy alcohol use. Given the severe thrombocytopenia, out of proportion to usual levels seen in cirrhosis, the hematology/oncology service was consulted. Trans-jugular liver biopsy showed extramedullary hematopoiesis and myelofibrotic changes with superimposed mast cell neoplasm. Subsequently, bone marrow biopsy also revealed erythroid hyperplasia with marked dyserythropoiesis, consistent with myelodysplastic syndrome, in addition to extensive bone marrow involvement by malignant mast cell neoplasm.

DISCUSSION:

Resultant hepatosplenomegaly from PMF in patients may lead to non-cirrhotic portal hypertension, which can lead to variceal bleeding or ascites. These symptoms prior to systemic manifestations of a myeloproliferative neoplasm, are rare. Acute liver failure, as the initial presentation of PMF and mast cell neoplasm is not commonly reported in medical literature. The overall prognosis is generally poor with liver involvement an indicator of an advanced stage of the disease.
2205 Bupivacaine-Induced Liver Injury: A Diagnostic Dilemma
Authors: Syed Tausif A. , Patel Sameer , Alweis Richard
Published: October 2019

INTRODUCTION:

Bupivacaine is local anesthetic (1). Very few cases of bupivacaine induced liver injury have been noted in the literature; we report a case of this very rare side effect (2).

CASE DESCRIPTION/METHODS:

A 69-year-old male patient underwent a right inguinal herniorrhaphy. One week after the surgery, patient began to have nausea, vomiting, fever, and dark brown urine. Stools were normal and there was no pruritis. There was no previous history of jaundice, chronic liver disease or malignancy. New medication use, alcohol, illicit drug use, risky sexual behavior was negative. On examination, vitals were all within normal limits. Icterus was present but otherwise his skin was only remarkable for the left lower quadrant scar, which was healing well without surrounding erythema or purulent discharge. Liver function tests were notable for a total bilirubin of 17.4 mg/dL, direct bilirubin was 10.8 mg /dL,. AST was 355 U/L, ALT was 570 U/L, alkaline phosphatase was 944 U/L, LDH was 315 U/L. Viral, autoimmune and structural causes of acute hepatitis were excluded. Given the negative evaluation, a retrospective review of medications received during and after surgery was performed, and the patient was found to have received bupivacaine via PCA post-operatively. As all the other options were excluded, the patient was diagnosed with liver injury from bupivacaine. The patient was managed conservatively and recovered fully in about four weeks.

DISCUSSION:

Bupivacaine is a local anesthetic which can be given through elastomer pumps for pain control (1). There are case reports in the literature that suggested bupivacaine can cause liver injury when given for more than one week (2,3). DILI is a diagnosis of exclusion (2,4). The common causes of liver injury such as drugs, alcohol, viruses, autoimmune diseases and biliary tract abnormalities need to be excluded (4). The diagnosis can be established with the help of Naranjo criteria (5) (Table 1). Most of these liver injuries respond to conservative management. There have been no reports of any acute or chronic liver failure in such cases. If the patient is at high risk of liver injury then they should receive local anesthetic agent other than bupivacaine (3).
2206 Nodular Regenerative Hyperplasia in a Patient With Sickle Cell Disease
Authors: Bedi Simranjit , Tosounian Shannon L. , Miick Ronald , Au Jennifer
Published: October 2019

INTRODUCTION:

Nodular regenerative hyperplasia (NRH) is a rare liver condition caused by transformation of hepatic parenchyma into regenerative nodules. Despite the association between NRH and certain hematologic disorders, specifically myeloproliferative diseases, there are very few reports of NRH associated with sickle cell disease (SCD). We present a patient with SCD with liver biopsy confirmation of NRH and sickle cell hepatopathy.

CASE DESCRIPTION/METHODS:

A 45-year-old male with history of hypertension and sickle cell anemia (hemoglobin SS phenotype) was initially referred to hepatology due to concerns for cirrhosis on CT scan. He had been admitted for significant fatigue and a CT thorax was obtained due to opacity on chest X-ray. This study showed findings concerning for cirrhosis with high density in the liver suggesting hemosiderosis; this was new compared to imaging five years prior. Upon initial evaluation in clinic, he was asymptomatic and fatigue had resolved since receiving blood transfusion during his hospitalization. He had normal vital signs and benign physical exam. Pertinent laboratory results included: AST 39 IU/L, ALT 19 IU/L, Total Bilirubin 2.35 mg/dL (Direct Bilirubin 0.7 mg/dL), Alkaline Phosphatase 81 IU/L, INR 1.0, Hemoglobin 8.3 gm/dL. His ferritin was 1021 ng/mL, a hepatitis panel was negative, and anti-mitochondrial antibody was elevated at 24.5 units. A liver ultrasound with dopplers demonstrated increased echogenicity, mildly coarse echotexture, with an irregular contour consistent with cirrhosis. To delineate the cause of his liver disease, a percutaneous liver biopsy was obtained. Findings on pathology were consistent with sickle cell hepatopathy with nodular regenerative hyperplasia, mild hepatocellular and Kupffer cell siderosis, and no fibrosis. He is planned for interval follow up with hepatology.

DISCUSSION:

SCD is associated with several liver complications including infarcts, abscesses, and hemosiderosis, with NRH being an uncommon complication. The proposed mechanism of NRH as it relates to SCD is due to obstructive portal venopathy resulting in areas of compromised blood flow with regenerative nodules forming in other areas of the liver to compensate for this. As it is asymptomatic with a prolonged subclinical period, it is frequently missed, however early recognition is important to avoid complications related to non-cirrhotic portal hypertension. This case highlights a very rare association between NRH and SCD.