bluuebunny/crossref_metadata_2025 huggingface dataset:
1823 Esophagitis in Immunocompromised Patient From Strongyloides Reactivation
Authors: Zivari Kaveh , Yunina Daria , Grunwald Matthew , Azar Omar , Tin Kevin , Rahmani Rabin
Published: October 2019

INTRODUCTION:

Strongyloides Stercoralis infection affects as many as 30 million people in 70 countries worldwide. It also can undergo cycles of autoinfection leading to chronic disease. This infection is usually asymptomatic and may remain undetected for decades. However, in patients who are immunocompromised, such as patient’s undergoing chemotherapy, receiving long-term corticosteroids, transplant patient, or patient with HIV; severe infection can occur and result in mortality rates as high as 87%. Strongyloidiasis is difficult to diagnose as the parasite load is low and the larval output is irregular.

CASE DESCRIPTION/METHODS:

79-year-old Chinese migrant man with metastatic lung adenocarcinoma who was recently started on Erlotinib, presented with nausea, vomiting, diarrhea, generalized weakness, and epigastric pain. He had White Blood Cell count of 7.6 with 6.6% Eosinophils. X-ray and Computed Tomography imaging did not show any changes from prior studies. Esophagogastroduodenoscopy was performed afterwards which showed esophagitis, gastritis, duodenal ulcer and duodenitis. Subsequently, biopsies of the duodenal and esophageal mucosa revealed parasitic larvae consistent with Strongyloides Stercoralis (Figure 1). The patient was started on Ivermectin and had resolution of his symptoms on follow up. Erlotinib was resumed after discharge.

DISCUSSION:

Although differential diagnosis for esophagitis in immunocompromised patients is broad, our patient was interestingly diagnosed with Strongyloides induced esophagitis via biopsy. The larvae of Strongyloides have potential ability to invade and survive for extended periods in human tissue. They have obligatory tissue phase in which the larvae follows from the portal of entry and eventually to trachea and lung. Depressed cell-mediated immunity secondary to malignant tumor, combined with protein-calorie malnutrition, led to lack of granulomatous immune response to larvae in our patient. Several immunodiagnostic assays have been found ineffective in detecting disseminated infection. Although it is important to detect latent S. Stercoralis infections before administering chemotherapy or before the onset of immunosuppression in patients at risk, a specific and sensitive diagnostic test is lacking. When acute esophagitis does present, it may be severe and disabling, and could result in hospitalization, placement of a feeding tube in the stomach or parenteral nutrition, and steady supportive care. Biopsy, cytology, and culture are recommended for suspected cases.
1826 74-Year-Old Man With Esophageal Adenocarcinoma and Right Sided Weakness: Is Brain Involved?
Authors: Omar Abelardo Escriba , Bashashati Mohammad , Moreno Jorge , Deoker Abhizith , Corral Javier
Published: October 2019

INTRODUCTION:

Esophageal cancer with an incidence of 4.3 per 100,000 per year and a death rate of 4.0 per 100,000 per year accounts for about 1% of all cancers diagnosed in the US. Within the past four decades, while the incidence of esophageal cancer has remained stable in the US, an increasing trend for the adenocarcinoma form has been observed in men mainly due to increased obesity and gastroesophageal reflux disorders. Remarkably, Hispanic-Americans have a lower rate of esophageal cancer. Brain metastasis from esophageal cancer is an extremely rare condition with an incidence of 0.6-1.5%. Here we report a Hispanic-American white patient with brain metastasis from esophageal adenocarcinoma.

CASE DESCRIPTION/METHODS:

74-year-old Hispanic man with history of esophageal adenocarcinoma status post chemo-radiation with resection and gastric pull-through was referred to our hospital 4 years after surgery due to progressive left upper and lower extremity weakness, left facial droop and slurred speech for almost a month. He denied any prior history of headache, trauma, weakness or falls. Brain MRI showed a 61.6 x 47.3 x 45.0 mm heterogeneous/enhancing/intra-axial tumor projected at the level of the right supramarginal gyrus, and another smaller 9 mm intra-axial enhancing lesion in the medial aspect of the right superior temporal gyrus associated with perilesional vasogenic edema and 12 mm right to left midline shift (Figure 1). CT thorax, abdomen and pelvis did not reveal any mass or lymphadenopathy. The patient underwent a right-sided temporal craniotomy for resection of the temporal hemorrhagic tumor with a moderately hard capsule and significant fibrous adhesions invading the M2 branch of the middle cerebral artery with a small rim of tumor left along the back of the middle cerebral artery. He was scheduled for Whole Brain Radiation Therapy (WBRT) showing an improvement in his muscular strength. Pathology report demonstrated metastatic brain adenocarcinoma from the esophagus (Figure 1).

DISCUSSION:

Brain metastasis is a rare condition which should be suspected in patients with esophageal cancer and neurological manifestations. Routine preoperative neuroimaging is not recommended for identification of occult brain metastasis in esophageal cancer rather than in those with a primary esophageal tumor of >8 cm in diameter. Prognosis of this condition is overall poor and treatment should be personalized based on the patient’ general condition. When brain mass is resectable, surgery followed by WBRT is recommended.
1827 Concurrent Barret’s Esophagus and Esophageal Varix With Resolution After Banding
Authors: Rivera Arturo Suplee , Rapoport Grigoriy , Castano Juan J. , Zamir Asif , Nathani Muhammed
Published: October 2019

INTRODUCTION:

Barret’s esophagus with dysplasia is a premalignant condition frequently treated with radiofrequency ablation. However, the management of concurrent dysplasia with esophageal varices (EV) is not defined. Medical literature on this topic is scant and consists of a few case reports. The following is a case of Barret's esophagus with low grade dysplasia and concurrent esophageal varices, successfully treated with band ligation.

CASE DESCRIPTION/METHODS:

The patient is a 50-year-old man with a history of liver cirrhosis, who presented to our gastroenterology clinic for routine evaluation. His only complaint was chronic heartburn. EGD was significant for grade I esophageal varices and a small segment of columnar epithelium on a variceal segment. Biopsy results were positive for BE with low grade dysplasia. The patient was started on a proton pump inhibitor and scheduled for follow-up. Patient was placed under surveillance with annual EGD. Frequent discussions were held regarding the risks vs benefits of the different treatment options. Next endoscopy revealed progression of his EV to grade II and a persistent area of columnar epithelium on one of the varices. A decision was made to band 2 varices, including the one with Barrett’s epithelium. Repeat endoscopy one year later demonstrated complete resolution of both, the varix and the columnar epithelium. Biopsy was negative for dysplasia and metaplasia. Ten years later, with yearly follow-up, endoscopy continues to be unremarkable in the banded segment.

DISCUSSION:

Epidemiology of BE and its relationship with adenocarcinoma has been extensively described in literature, however it is unknown what percentage of these patients have underlying liver cirrhosis with complications such as EV. This maybe be due to decreased life expectancy of these patients and the lack of routine endoscopic screening.We expect to face more of these challenging cases due to improved life expectancy of cirrhotic patients and the more readily available screening, such as endoscopic procedures for esophageal varices. Our case presents a novel method of treating this unique and difficult clinical scenario. However, we need more cases to validate our work.
1829 A Case of Poorly Differentiated Neuroendocrine Neoplasm of the Esophagus
Authors: Gala Khushboo , Hassan Syed , Parajuli Dipendra
Published: October 2019

INTRODUCTION:

Esophageal cancer is a growing public health concern, with its prevalence expected to increase by 140% in the next 10 years. The most common types of esophageal tumors include squamous cell carcinoma and adenocarcinoma, which account for more than 95% of cases, however there are some rarer types of esophageal tumors. We describe a case of poorly differentiated neuroendocrine cancer of the esophagus.

CASE DESCRIPTION/METHODS:

A 51-year-old Caucasian male with past medical history of hypertension presented with upper abdominal pain for a month. CT abdomen revealed a large 4.5 x 3.5 cm mass in the gastrohepatic region, which prompted endoscopy. He was found to have an ulcerated, cratered 3.5 cm lesion at the mid esophagus on a background of salmon colored mucosa. Pathology showed a poorly-differentiated neuroendocrine carcinoma on a background of Barrett's esophagus, with positive CAM5.2 cytokeratin and CD56 markers and a Ki67 index of 90%. Staging PET-CT showed metastatic lymph nodes in mediastinum and abdomen, as well as metastatic involvement of liver. He was started on systemic chemotherapy with etoposide and cisplatin, and is following with outpatient oncology for further management.

DISCUSSION:

Neuroendocrine neoplasms (NEN) of the esophagus are very rare, representing only 1% of esophageal malignancies. As in our case, NENs usually occur in older individuals and more commonly in men. Like most esophageal malignancies, they present with dysphagia, abdominal pain, systemic symptoms and at late stages, obstruction; notably, they rarely secrete hormones. On endoscopy, they are usually seen as a subepithelial lesion: a polypoid, nodular elevated lesion with smooth and glistening overlying surface. Diagnosis is made on biopsy, showing the characteristic neuroendocrine cells with abundant neurosecretory granules, which have positive immunohistochemical expression of neuroendocrine markers like synaptophysin and chromogranin. Prognosis depends on the extent of metastasis, determined by cross-sectional imaging and PET-CTs. In general, small superficial NENs < 1 cm can be managed by endoscopic mucosal resection/dissection and NENs >2 cm are treated with surgical resection. For metastatic disease, like in our case, chemotherapy is administered with a combination of platin salts and etoposide. The prognosis for these large tumors remains poor; however rising prevalence of these pathologies warrants a high level of awareness of the condition with treatment options.
1831 Pericardioesophageal Fistula Formation Following Ventricular Tachycardia Ablation: Case Presentation With Discussion of Incidence and Treatment
Authors: Shams Christienne , Patwardhan Soumil , Kulesza Gregory
Published: October 2019

INTRODUCTION:

Cardioesophageal fistulas following radiofrequency ablation (RFA) for atrial fibrillation is a rare but increasingly recognized complication of the procedure with an estimated annual incidence rate of 0.03-0.04%. While atrioesophageal fistulas require surgical management, pericardialesophageal fistulas can often be conservatively managed. The fistula formation is believed to be due to the inflammatory cascade initiated from thermal injury and subsequent degradation of tissue boundaries. Though reported following atrial ablation, it has not been reported with ventricular ablation. Here, we present a case of pericardioesophageal fistula following RFA for ventricular tachycardia.

CASE DESCRIPTION/METHODS:

61-year-old male presented to the emergency department complaining of fever, chest pain and dyspnea following inferolateral wall ablation and scar homogenization two weeks prior. He had a history of cardiomyopathy with AICD placement and refractory ventricular tachycardia due to ischemic heart disease. CT angiogram ruled out PE but demonstrated a pneumopericardium, later confirmed by echocardiogram. He subsequently developed signs of sepsis with profound hypotension requiring pressor support and underwent a pericardial window and indwelling pericardial drain placement. Due to fibrinous septations, tPA was infused to facilitate the purulent drainage. Fluid cultured from the pericardial window grew Staphylococcus epidermis and gram-negative bacilli. EGD was preformed with a 2 cm diameter pericardioesophageal fistula 4 cm above the GE junction and 36 cm distal to the incisors. He had a fully covered esophageal stent placed given poor nutritional status and poor surgical candidacy. His hospital course was further complicated by vent dependent respiratory failure, acute renal failure, recurrent DVTs with an upper GI bleed due to a contained rupture of an esophageal hematoma necessitating the placement of an IVC filter. Follow-up endoscopy two months following placement demonstrated stent migration but a healed pericardioesophageal fistula.

DISCUSSION:

This case demonstrates the importance of considering pericardioesophageal fistula as a complication of ventricular ablation. Treatment options are variable and they are often managed endoscopically as a temporizing measure until surgery can be safely performed. Here, we report the first case, to our knowledge, of pericardioesophageal fistula following ventricular ablation successfully managed with supportive measures.
1836 The Bougie Cap: A Novel Device for Treatment of Esophageal Strictures
Authors: Ramrakhiani Hannah , Triadafilopoulos George
Published: October 2019

INTRODUCTION:

Treatment of high cervical esophageal strictures can be technically challenging. Placement of endoscopic balloons across the stricture may not be feasible due to their proximal location. Serial dilation with the use of Savary-Gilliard dilators is a well-established method for treatment of these strictures. However, this technique does not allow for direct optical feedback during dilation. We present a case of benign cervical esophageal stricture treated with a novel method utilizing the BougieCap (Ovesco Endoscopy AG).

CASE DESCRIPTION/METHODS:

A 62-year-old male presented with dysphagia. He had a prior history of peptic stricture at the gastroesophageal junction, treated with multiple balloon dilations that was complicated by an esophageal perforation. Patient underwent an emergent thoracotomy, esophagectomy, and gastric pull-up with placement of a feeding jejunostomy. Four months after surgery, he noted recurrence of dysphagia, with food getting lodged in the area below his throat and upper chest. Barium swallow revealed a tight stricture at the anastomosis that narrowed the lumen down to 5 mm in size. Upper endoscopy confirmed a stricture located 18 cm from the incisors. Using an endoscopic BougieCap the stricture was dilated serially from 7 to 12 mm in size with good results. Expected mucosal disruption was identified at the end of the procedure. On follow up, patient reported significant improvement in his symptoms without any complications.

DISCUSSION:

Use of Savary-Gilliard Dilators for stricture dilation provides only haptic control and often requires the use of fluoroscopic guidance. Our case highlights the use of a novel device - the BougieCap - for treatment of esophageal strictures which allows for direct visual control and optical feedback during the procedure. Ability to visualize the tension on the tissue while passing the stricture with the cap avoids overstretching and may help reduce the risk of complications, allowing for a more effective procedure. Moreover, by eliminating the need to switch instruments, the use of BougieCap can reduce procedure times. Additional prospective studies with a larger number of patients and long-term follow-up are necessary to determine its safety and long-term efficacy.
1837 Potassium-Binding Resin Induced Esophageal Pseudo-Tumor
Authors: Chavez Luis O. , Bustamante Marco A. , Padilla Osvaldo , Gavito-Higuera Jose , Zuckerman Marc J.
Published: October 2019

INTRODUCTION:

Sodium Polystyrene Sulfonate (SPS) is a resin used to treat patients with hyperkalemia. It has been associated with several gastrointestinal complications, most commonly colonic necrosis. Patients with certain comorbidities are at risk for gastric and esophageal lesions. We describe a case with unusual endoscopic findings secondary to SPS-induced mucosal injury.

CASE DESCRIPTION/METHODS:

An 83-year-old male with a medical history of coronary artery disease presented with a 1-month history of progressive dysphagia, vomiting, cough, melena and a 25 pound weight loss. He denied any home medications, but in a recent hospitalization patient received antibiotics for pneumonia and prolonged treatment with SPS for hyperkalemia. Physical examination was remarkable for tachycardia (110 bpm), and a cachectic appearance. Laboratory results showed a white blood cell count of 8080/mm3, hemoglobin of 9.3 g/dl, mean corpuscular volume 92.8 fl, platelets 432,000/mm3, and a potassium of 5.7 mEq/L. A chest CT without contrast revealed a dilated esophagus with an achalasia-like appearance and a focal region of wall thickening adjacent to the gastroesophageal junction. (Figure 1) An esophagogastroduodenoscopy (Figure 2) was performed showing diffuse severe congestion, erythema, and deep ulcerations in the esophagus. A partially obstructing mass in the lower third of the esophagus was identified. Biopsies were obtained and a nasogastric tube (NGT) was placed for nutrition support. Histopathology showed esophageal squamous mucosa with foci of mixed acute/chronic inflammation and basophilic rhomboid crystals forming a mosaic pattern (consistent with SPS crystals). (Figure 3) Patient was started on omeprazole 40 mg twice a day through the NGT resulting in mild improvement of symptoms.

DISCUSSION:

We present a case of esophageal mucosal injury secondary to SPS mimicking an esophageal carcinoma. The mucosal changes are secondary to prolonged exposure of SPS to the epithelium causing ischemic necrosis. The identification of basophilic crystals in the epithelium with surrounding inflammation is a hallmark of SPS-induced mucosal injury. SPS esophagitis may affect the entire or distal esophagus. Findings of mucosal thickening and cobblestone appearance are usually present. Other endoscopic findings may mimic different conditions such as Candida esophagitis or gastric bezoar. In our case, the deep ulcerations, extensive inflammation and the mass-like thickening of the mucosa imitated an esophageal carcinoma.
1840 Salivary Gland Choristoma: A Rare Finding at Gastroesophageal Junction
Authors: Comba Isin Y. , Henriquez Richard , Kumar Sundeep , Merino-Chavez Hilda , Wallis-Crespo Maria , Cooper Christopher , Bhatia Lakhinder
Published: October 2019

INTRODUCTION:

Choristoma is tumor-like outgrowth of heterotopic and mature tissue located at anatomically unusual sites. Heterotopic salivary gland tissue (HSGT) has been most commonly described in head and neck region but can rarely involve gastrointestinal (GI) tract with a few cases reported in the literature.

CASE DESCRIPTION/METHODS:

An 87-year-old female with past medical history of gastroesophageal reflux disease (GERD), hypertension, and chronic kidney disease was admitted for an acute DVT. Due to worsening anemia, she underwent an upper endoscopy that showed a small nodularity at the GE junction (Figure 1a), a large hiatal hernia, and reflux esophagitis in the lower one-third of the esophagus (Figure 1b). Biopsy of the nodule demonstrated an esophagogastric junction-type mucosa with mild to moderate chronic inflammation, mild acute inflammation and focal glandular tissue consistent with heterotopic salivary gland tissue (Figure 1c, d). No intestinal metaplasia or dysplasia were noted.

DISCUSSION:

Salivary gland choristoma at the gastroesophageal junction (GEJ) is an extremely rare entity, with only one case reported in the English literature. Additionally, two other cases of HSGT at GEJ not in the form of choristoma were described in the same report. All of the cases had a medical history of GERD. One of the HSGT cases had reflux esophagitis while the other had Barret’s esophagus with high-grade dysplasia. Similarly, our patient had a history of GERD with reflux esophagitis. She was diagnosed incidentally, through an EGD-guided biopsy of the nodule to exclude malignancy. It is well-known that intestinal columnar metaplasia at the GEJ can occur secondary to chronic acid exposure and inflammation in the setting of GERD. The origin of these intestinal glandular cells remains unknown. Furthermore, pancreatic acinar metaplasia at the GEJ is a relatively common finding, but the causative relationship between GERD and pancreatic acinar metaplasia is obscure. Salivary gland choristoma of the GEJ could be a metaplastic change in the setting chronic inflammation as a result of reflux esophagitis. However, the biological and clinical significance of this finding is yet to be investigated.
1842 Retroperitoneal Fibrosis: A Presenting Symptom of Esophageal Adenocarcinoma
Authors: Dhanani Zehra , Madanchi Nima , Dia Sunita , Distajo Ronald
Published: October 2019

INTRODUCTION:

Retroperitoneal fibrosis can be idiopathic or secondary to drugs, infections, radiotherapy, surgery, trauma, amyloidosis, or malignancies. There are very few reported cases of retroperitoneal fibrosis related to esophageal cancer and none of them have reported retroperitoneal fibrosis as the presenting feature of esophageal adenocarcinoma.

CASE DESCRIPTION/METHODS:

A 68-year-old female with a past medical history of psoriasis and type-one Chiari malformation presented with one month of progressive abdominal and lower back pain. CT abdomen pelvis revealed inflammatory changes around the aorta, celiac artery, SMA and renal artery with severe narrowing of both renal veins and near obliteration of the IVC. Infectious work-up including TB, Syphilis, Hepatitis B and C, and rheumatologic work-up including ANA, ENA, RF, CCP and IgG4 were negative. Patient continued to have worsening symptoms and worsening kidney failure despite bilateral nephrostomy, high-dose steroid and empiric antibiotics. Eventually, patient underwent upper endoscopy for episodes of bilious vomiting which revealed esophagitis and nodularity in lower third esophagus. Esophageal biopsy showed poorly differentiated adenocarcinoma. Retroperitoneal biopsy also demonstrated the same morphological features consistent with an esophageal source.

DISCUSSION:

To the best of our knowledge, this is the first report of an esophageal adenocarcinoma presenting with retroperitoneal fibrosis with complete absence of dysphasia, odynophagia and weight loss. Patient did not experience any GI symptoms until late in the disease course. Malignancy-related retroperitoneal fibrosis can be secondary to either metastasis/invasion from a solid tumor or due to release of fibroblast-stimulating cytokines. Cytokine release is most commonly seen in carcinoid tumors. It is associated with poor prognosis. The nonspecific presenting symptoms, as witnessed in our patient, make it difficult to reach a diagnosis. By the time the patient has more clear symptoms of malignancy, it is often too late for curative treatment. There is currently a lack of effective therapies to treat retroperitoneal fibrosis. Corticosteroids are commonly employed in idiopathic cases however their use in malignancy-related cases has not been effective. Palliative chemotherapy or surgery might be effective for symptomatic management. In conclusion, we recommend considering esophageal cancer as a differential diagnosis in unexplained retroperitoneal fibrosis.
1843 A Rare Case of Large Cell Neuroendocrine Carcinoma of the Esophagus
Authors: Gioe Reed , Gioe Scott
Published: October 2019

INTRODUCTION:

Neuroendocrine Tumors (NETs) are a rare form of esophageal malignancy with an incidence ranging from 0.4 and 2% of all malignant esophageal tumors (1). Among esophageal NETs, the vast majority are small cell esophageal carcinomas. A recent literature review found only 35 cases of large cell esophageal carcinoma have been reported since 1952 (2).

CASE DESCRIPTION/METHODS:

Patient is a 48-year-old male with past medical history of HTN, diabetes, and HLD who presented with 6 weeks of progressive dysphagia predominantly to solids. The dysphagia was initially infrequent, but eventually occurred every time he ate. ROS was pertinent for a 20 lb weight loss. Social history was pertinent for 1-2 drinks of alcohol per month and daily use of chewing tobacco. Family history revealed a mother with a brain mass and a grandmother with pancreatic CA. PE was normal. He underwent an EGD which showed a large, ulcerative distal esophageal mass extending into gastric cardia. Biopsies revealed a poorly differentiated carcinoma most compatible with large cell neuroendocrine carcinoma. CT imaging of chest, abdomen, and pelvis showed nonspecific lower esophageal mural thickening with no evidence of esophageal mass. PET scan showed hypermetabolic distal esophageal mass measuring 6 x 5 x 3 cm with peri gastric lymph node involvement. The patient underwent neoadjuvant treatment with radiation, cisplatin and etoposide followed by a distal esophagectomy with gastric pull-through. Surgical path revealed Stage III large cell neuroendocrine carcinoma involving the distal esophagus, proximal stomach, and peri gastric lymph nodes. Patient is currently recovering from the surgery with plans for postoperative chemotherapy.

DISCUSSION:

This case illustrates an rare form of a malignant esophageal neuroendocrine tumor. Esophageal NETs tend to be more aggressive than NETs found in other parts of the GI tract, so early diagnosis and treatment is critical in order to prolong survival. Due to a paucity of cases in the literature, there is a need for more cases to be presented in order to better understand the course of the disease and determine the best modalities for treatment.
1845 Rapidly Progressive Dysphagia as Presenting Symptom of Gastrointestinal Amyloidosis
Authors: Gandle Cassandra , Millien Valentine , Tasleem Syed , Bloomquist M. Suzanne , Choi Eunice , Hernaez Ruben , Cole Rhonda A. , Ketwaroo Gyanprakash Avinash
Published: October 2019

INTRODUCTION:

Amyloidosis is a rare condition caused by the extracellular deposition of protein fibrils. The presence of these proteins in organs and tissues interferes with their ability to function normally. Amyloidosis commonly causes cardiomyopathy, neuropathy, and proteinuria. Gastrointestinal involvement in amyloidosis is less common and can either be isolated to the GI tract or systemic. When the GI tract is involved, patients typically present with symptoms such as bleeding, diarrhea, constipation, and steatorrhea. We present a case of gastrointestinal amyloidosis with rapidly progressive dysphagia as the presenting symptom.

CASE DESCRIPTION/METHODS:

A 70-year-old man presented with progressive dysphagia over one month. At first he noted difficulty swallowing meat. However, in the days leading up to admission he found that it took more effort to swallow liquids. He denied difficulty initiating swallow and endorsed a globus sensation after swallowing. Laryngoscopy was unremarkable. On EGD, the esophagus and duodenum appeared normal. Mild gastric erythema was present and biopsies were obtained of the esophagus and stomach. The esophageal biopsies were consistent with AL (lambda)-type amyloidosis. Congo red-positive amyloid deposits were present. Liquid chromatography tandem mass spectrometry (LC MS/MS) detected a peptide profile consistent with this diagnosis. Biopsies from the stomach and duodenum also had increased lamina propria fibrosis consistent with amyloidosis. Several weeks after this diagnosis was made, the patient expired due to an unrelated cause.

DISCUSSION:

AL amyloid is the most common type of amyloidosis however it very rarely involves the GI tract. Biopsy proven disease is found in approximately 8% of cases with only 1% of patients experiencing symptoms at the time of diagnosis. AL amyloidosis is typically associated with systemic disease due to an underlying clonal plasma cell proliferation or B-cell lymphoma. The patient described expired before further work-up could be completed. Dysphagia is an uncommon symptom of gastrointestinal amyloidosis and very few cases have been reported in the literature to date. Our case demonstrates an unusual presentation of a rare illness.
1852 Acute Gastroparesis Syndrome After Percutaneous Atrial Fibrillation Ablation
Authors: Leung Marcia , Pan Dana , Terrado Cecilia
Published: October 2019

INTRODUCTION:

Percutaneous radiofrequency ablation (RFA) is now a common minimally invasive procedure for the maintenance of sinus rhythm in drug-resistant atrial fibrillation. We present a rare case of acute delayed gastric emptying after an RFA procedure.

CASE DESCRIPTION/METHODS:

57-year-old male with a history significant only for paroxysmal atrial fibrillation, who presented for a planned RFA procedure. He has no other medical or surgical history. The patient tolerated the procedure well and was discharged the same day. That evening, 1-2 hours after he ate dinner, he experienced severe nausea, vomiting, and abdominal pain. He was hemodynamically stable on presentation to the emergency department with labs significant only for a mild leukocytosis. Computed tomography showed a severely dilated stomach and proximal duodenum, with a transition point identified at the third portion of the duodenum. The patient was managed conservatively as a case of proximal small bowel obstruction. As he had mild improvement in symptoms after five days, the decision was made for an exploratory laparotomy. An intra-operative push enteroscopy demonstrated large amounts of retained food in the stomach, but no gastroduodenal outlet obstruction. A diagnosis of acute gastroparesis syndrome was made, and surgical exploration was not done. The patient was discharged, managed conservatively, and on follow-up 4 weeks later his symptoms had significantly improved.

DISCUSSION:

Acute gastroparesis syndrome is a rare complication of RFA for atrial fibrillation, that occurs due to thermal injury to the peri-esophageal vagal nerves during ablation. Symptoms of nausea, bloating, vomiting, gastric pain occur within 72 hours after the procedure. Most patients fully recover within 1-2 months after the procedure with conservative management. However, a few reported cases with persistent symptoms required eventual esophagojejunal anastomosis or intra-pyloric botulinum injection. Due to wide variation in vagal plexus anatomy around the lower esophagus, and lack of visualization of the nervous system, nerve injury is hard to avoid. Higher BMI was noted to be a protective. Minimizing RF ablative power around the esophagus and/or esophageal temperature monitoring may be a strategy to lower the risk. As RFA ablation for atrial fibrillation becomes more common, gastroenterologists should be aware of this complication.
1854 Conservative Management of Pneumatosis Cystoides Intestinalis With Pneumoperitoneum in a Scleroderma-Related Illness
Authors: Nwaichi Chineme , Ajiboye Oyintayo , Randhawa Tejinder , Gevorgyan Ofelya , Attar Bashar M.
Published: October 2019

INTRODUCTION:

Pneumatosis Cystoidea Intestinalis with pneumoperitoneum in scleroderma-related illness could mimic an acute abdomen, presenting with pseudo-obstruction and gas within and outside the intestinal wall in the absence of a true perforation of the intestinal wall. The recognition of the clinical presentation of pseudoobstruction with pneumoperitoneum, due to Pneumatosis Cystoidea Intestinalis is paramount for the clinical decision to manage conservatively and avoid a surgical intervention.

CASE DESCRIPTION/METHODS:

A 30-year-old female with a 3-year history of limited scleroderma and myositis overlap presented with worsening nausea, vomiting, abdominal pain and bloating for about a week. She had a similar episode about a month prior to presentation, with abdominal imaging showing intestinal wall blebs with pneumoperitoneum, and had undergone an exploratory laparotomy. There was no bowel perforation on exploratory laparotomy and biopsy results showed fibrous tissues lined by reactive mesothelial cells and chronic inflammation. On examination, her abdomen was distended with epigastric tenderness, without guarding or rebound tenderness. An abdominal x-ray and CT scan revealed small bowel obstruction with pneumoperitoneum, features characteristic of Pneumatosis Cystoidea Intestinalis. She was evaluated by gastroenterology, surgery and the rheumatology team, and managed conservatively with intravenous fluids, nasogastric tube decompression, and administration of proton pump inhibitor. Her vital signs were normal and abdominal distension subsided with a resolution of her symptoms after 24 hours of conservative management. She was subsequently able to tolerate diet and was discharged on day 2 of admission with a plan for outpatient follow up.

DISCUSSION:

The presence of pneumoperitoneum portends a sinister finding in a patient with intestinal obstruction, often requiring surgical intervention. Pneumatosis Cystoides Intestinalis is characterized by micro-perforations of intestinal wall blebs which give rise to pneumoperitoneum, without a true perforation of the intestinal wall. The bacterial overgrowth and mechanical theory are both highlighted as mechanisms for the loss of integrity of the intestinal intimal layer, resulting in leakage and formation of gas within the intestinal wall. However, in the absence of acute peritonitis, abdominal abscess, and a worsening clinical status, Pneumatosis Cysotiodea Intestinalis can be managed conservatively in spite of a pseudo-obstruction with pneumoperitoneum.
1855 An Unusual Mimicker of Irritable Bowel Disease
Authors: Hodgeman Nicholas , Horn Christian L. , Paredes Angelo
Published: October 2019

INTRODUCTION:

Delayed anaphylactic reaction to red meat is a rare phenomenon that was first recognized during clinical trials for cetuximab. Through careful retrospective study of the patients afflicted, it was discovered there was a geographic overlap with the Amblyomma americanum tick, also known as the lone star tick. These patients were also found to have IgE antibodies to the peptide galactose-alpha-1,3-galactose (α-gal), commonly found in non-primate mammalian meat. Since the trials with cetuximab, allergic reactions to red meat has been documented in patients who have not been exposed to cetuximab, believed to be caused by the bite of the lone star tick. We present the case of a 46-year-old male who was evaluated for 6 months of progressive gastrointestinal symptoms and was ultimately found to have elevated α-gal IgE levels.

CASE DESCRIPTION/METHODS:

A 46-year-old male was evaluated for 6 months of progressive abdominal distress following consumption of red meat. He reported severe nausea, vomiting and diarrhea that persisted for hours after consumption of red meat. He had not experienced anaphylaxis, but had a 40 pound weight loss since symptom onset. He had recently moved to Texas from Maryland and denied any outdoor recreation, to include camping, hiking, or known tick bites. Initial work up was unrevealing for infectious or inflammatory cause of his symptoms, and cross-sectional imaging was noncontributory. EGD and colonoscopy were notable only for mild esophagitis and duodenitis. Due to concern for α-gal syndrome and at the prompting of the patient and his wife, total serum IgE and α-gal IgE were drawn, both noted to be elevated at 6215 IU/mL and 0.2 kU/L (ULN < 0.10 kU/L) respectively. A presumptive diagnosis of α-Gal syndrome was made and he was referred to nutrition for dietary counseling. Following removal of red meat from his diet, he reported his gastrointestinal symptoms had markedly improved.

DISCUSSION:

This case demonstrates the unique and uncommon condition known as α-gal syndrome. Our presentation’s presentation was not as dramatic as other documented cases, which likely led to a delay in his initial diagnosis. Diagnosis is made by first noting an elevated serum IgE. Specific α-gal IgE levels can then be drawn, which if elevated has high sensitivity and specificity for this syndrome. Improvement on a red meat restricted diet is ultimately diagnostic. As was seen in this case, improvement is often drastic and long lasting if red meat products are avoided.
1856 Immediate Air-Tight Seal With a Padlock Clip Defect Closure System for Iatrogenic Colonic Perforation
Authors: O'Keefe Ryan , Pathirana Induruwa
Published: October 2019

INTRODUCTION:

Iatrogenic colonic perforations are an infrequent complication of endoscopy that often require immediate surgical repair. However, endoscopic suturing devices or endoscopic clips are increasingly being utilized for closure. Through-the-scope clips can have high rates of failure and often require multiple clips per closure to achieve a similar level success to over-the-scope clips. Ovesco over-the-scope clips (OTSC®) have been studied in small prospective studies with 89% successful closures of acute iatrogenic gastrointestinal perforations without adverse events1. More recently, the Padlock Clip® defect closure system has emerged as a newer over-the-scope clip with case reports showing high levels of efficacy and safety in a variety of uses. We present a case of iatrogenic colonic perforation repaired with the Padlock Clip with a concurrent laparoscopic air-leak test confirming immediate complete closure.

CASE DESCRIPTION/METHODS:

A 64-year-old female with a history of severe diverticulosis presented for routine colonoscopy for polyp surveillance. The patient became significantly uncomfortable with water irrigation and a perforation was identified approximately 20cm from the anal verge, likely consistent with a perforated diverticulum. The procedure was aborted with subsequent imaging confirming a sigmoid colon perforation. In the operating room, a Padlock Clip defect closure device was endoscopically deployed with subsequent laparoscopic leak test confirming immediate air-tight seal. A diet was subsequently initiated without evidence of a leak.

DISCUSSION:

This case illustrates the efficacy of an alternative over-the-scope clip in closure of an acute colonic perforation. Compared to prior over-the-scope clips, the Padlock Clip is easier to deploy with potentially similar rates of efficacy and safety. The design of the Padlock Clip better facilitates two-person deployment as opposed to the Ovesco OTSC®. The deeper cap length makes acquisition of tissue easier and obviates the need for additional graspers. This patient demonstrates the Padlock Clip system as a viable option for the management acute iatrogenic colonic perforations. Reference: 1Voermans RP, Le moine O, Von renteln D, et al. Efficacy of endoscopic closure of acute perforations of the gastrointestinal tract. Clin Gastroenterol Hepatol. 2012;10(6):603-8.
1857 Not the Average Pseudopolyp
Authors: Pathirana Induruwa , O'Keefe Ryan
Published: October 2019

INTRODUCTION:

Polyposis syndromes are rare and often undiagnosed or misdiagnosed in clinical practice. Presented here is a case of Cowden syndrome initially misdiagnosed as an atypical presentation of ulcerative colitis.

CASE DESCRIPTION/METHODS:

A 62-year-old male presented to the gastroenterology clinic for routine annual surveillance colonoscopy. He had undergone numerous colonoscopies for the past decade demonstrating pseudopolyps throughout the colon. Pathology revealed normal colonic mucosa, hyperplastic features, and inflammatory polyps. He denied a history of diarrhea or hematochezia, or a family history of inflammatory bowel disease. The patient was ultimately diagnosed with ulcerative colitis, placed on oral mesalamine treatment, and advised to undergo annual colonoscopy for dysplasia surveillance. On the date of encounter a thyroidectomy scar was noted on physical exam. The patient had undergone total thyroidectomy in the 1990’s for an unknown reason. Chronic lesions resembling papillomas were present on his buccal mucosa. Although he did not have a formal diagnosis of autism, the patient displayed several characteristics of the disorder throughout the encounter. The patient’s son had also been diagnosed with numerous non-adenomatous colon polyps and his father had passed from renal cell carcinoma. Given clinical suspicion for Cowden syndrome, an upper endoscopy was added to the annual colonoscopy demonstrating significant esophageal glycogenic acanthosis and extensive duodenal hamartomas. Colonoscopy again demonstrated numerous hamartomas throughout the colon. Genetic sequencing demonstrating a frame shift mutation in the PTEN gene was performed by Athena Diagnostics, diagnostic of Cowden syndrome. Subsequently his mesalamine was discontinued, his colonoscopy surveillance interval was increased to every five years, and annual screening for renal cell carcinoma screening was initiated. His son was advised to undergo genetic testing as well due to the syndrome’s autosomal dominant inheritance pattern.

DISCUSSION:

This case showcases the utility of highlighting rare clinical entities. The prevalence of Cowden syndrome is estimated to be only 1 in 200,000 to 250,000 individuals. Clinicians are proficient at diagnosing more common disease presentations; however, rare disorders such as polyposis syndromes can be unrecognized unless they are consistently reviewed outside of daily practice.
1859 Paperclip or Inferior Vena Cava Filter Probe? The Case of an Unusual Foreign Body
Authors: Ghosh Soumojit , Ghoulam Elie , Clarrett Danisa M. , Qureshi Kamran
Published: October 2019

INTRODUCTION:

Inferior vena cava (IVC) filters are mechanical devices used to prevent pulmonary embolism, often used in patients with recurrent venous thromboembolism while on anticoagulation, or who have a contraindication to anticoagulation. Despite its increasing popularity over the last two decades, they do not come without complications such as migration of the filter or its parts, perforation or protrusion into surrounding structures such as the small or large bowel, vasculature, diaphragm, or the retroperitoneal space. We herein present a case of duodenal perforation caused by a migrating IVC filter, of which there have only been a few reported cases.

CASE DESCRIPTION/METHODS:

The patient is a 61-year-old female with HTN, GERD, iron-deficiency anemia, and a history of DVT while on anticoagulation (s/p IVC filter placement in October 2011) who initially presented with complaints of dizziness. Her workup revealed a new anemia with no overt GI bleeding for which she underwent endoscopic evaluation. She was found to have a thin piece of metal in the second portion of her duodenum, thought to be a swallowed foreign body, possibly a paperclip, which was later denied by the patient. Several attempts at retrieval were unsuccessful. One week later, she developed sudden-onset, severe, epigastric pain with guarding. She presented to our emergency department where a CT abdomen/pelvis with contrast revealed an infrarenal IVC filter with protrusion of a prong through the lateral wall of the IVC into the duodenum, as well as protrusion of a prong through the posterior wall of the IVC into the superior aspect of the right iliopsoas muscle. Given the pain, she was ultimately taken for successful percutaneous removal via the right internal jugular vein by Vascular Surgery with endoscopic assistance by Gastroenterology. There was no involvement of the ampulla and the duodenum maintained insufflation following removal.

DISCUSSION:

With the advent of contemporary IVC filters, the migration rates are less than 1%. However, because of new prong hooks to prevent migration, they can lead to perforation of surrounding structures. Retrievable filters have been found to have higher rates of perforation than the permanent form, particularly when the retrievable filters are left in place longer than anticipated. As seen in this case, the importance of IVC filters are paramount to prevent pulmonary embolism, but in a patient with sudden onset abdominal pain, one must rule out IVC filter perforation into surrounding structures.
1860 Use of NBT Gastrostomy Tubes as Replacement Jejunal Feeding Tubes
Authors: Moore Ryan , Evans J. Robert
Published: October 2019

INTRODUCTION:

For severely neurologically impaired patients, feeding tubes are a life-sustaining measure. While most patients can tolerate direct feeding into the stomach via nasogastric feeding tubes or gastrostomy feeding tubes, these options may be unhelpful or dangerous for patients with gastric retention or severe gastroesophageal reflux. For such patients, feeding through a jejunostomy may offer a safe alternative. However, when the tube needs to be replaced there are limited options. We review our experience of using non-balloon tip (NBT) gastrostomy replacement tubes as replacement jejunostomy tubes.

CASE DESCRIPTION/METHODS:

We searched procedure and follow-up reports from an individual gastroenterologist (JRE) from 03/2015 to 11/2018 for patients with jejunostomy feeding tubes at a single sub-acute nursing facility. All four jejunostomy patients on record had received 20 French NBT gastrostomy replacement tubes as replacement jejunostomy feeding tubes. The NBT tubes have a collapsible mushroom-shaped tip which is placed in the stoma with an obturator. We reviewed the patient records to determine if NBT replacement tubes effectively delivered nutrition and medication, whether they resulted in complications, and with what frequency the tubes needed replacement.

DISCUSSION:

The patients’ records show that the improvised replacement jejunal feeding tubes performed quite well. Available records show that the patients were fed jejunally for periods ranging from 47 to 168 weeks. Replacement NBT tubes lasted from 28 to 609 days. During this period, the only complication suffered was internal detachment of the mushroom tip, which occurred 5 times (4 of which in a single patient). In each of these cases however, the bowel remained unobstructed and the tips passed through the alimentary canal. Patients retained overall good health in spite of neurological impairment. For patients requiring feeding interventions, but lacking adequate gastric function, jejunostomy feeding is often needed if enteral feeding is to be maintained. While there is at present a dearth of equipment designed specifically for jejunal feeding tube replacement, our experience suggests that NBT gastrostomy tubes may constitute a viable option for patients with jejunostomy tubes. These mushroom-tip tubes remain in place without occluding the jejunum, they clog infrequently due to the wide lumen, and they represent a readily available and easy to place option for patients who need jejunostomy tube replacement.