bluuebunny/crossref_metadata_2025_split huggingface dataset:
2148 A Mediastinal Abscess Due to Actinomcyes Odontolyticus Diagnosed by Endoscopic Ultrasound-Guided FNA
Authors: Halim Nasir , Theethira Thimmaiah , Roytman Marina , Saligram Shreyas 
Published: October 2019

INTRODUCTION:
Thoracic Actinomyces is a rare infection but potentially aggressive. It is difficult to diagnose most often requiring surgical debridement. Actinomyces species colonize the mucosa of the body with disease potentially related to barrier injury.

CASE DESCRIPTION/METHODS:
A 29 year old male with history of childhood asthma and recent dental extraction presented with odynophagia. He noted chest discomfort & fevers. Physical exam revealed an obese male but was otherwise unremarkable. Oral exam was unrevealing for lesions. Labs noted a WBC of 16.8 u/L. CT Chest revealed a 5 × 2 × 2 cm posterior mediastinum collection (Figure 1) abutting the esophagus with mid and distal esophagitis. An EGD noted distal esophagitis, posterior extrinsic compression from 25 to 31 cm with a mucosal fistula at 27 cm with purulent drainage. Aspirated Esophageal contents were sent for culture. An IR Guided Drainage approach was not felt to be safe due to possibility of spinal injury. Patient underwent conservative treatment with PPI, Broad spectrum antimicrobial therapy. A repeat CT CAP revealed interval decreased size of mediastinal collection. Fluid cultures from endoscopy were negative. Testing for Coccidiomycosis, HIV, and Tuberculosis were negative. On Hospital Day 4, EGD and EUS was performed to evaluate the mediastinal abscess. EGD showed that the fistula had healed but there was esophageal rings and furrows; This was biopsied. The EUS noted a 1.5 × 2 cm Posterior Mediastinal Abscess. It was loculated and hard; A EUS guided FNA needle was used to obtain material for culture. Biopsies revealed >100 Eosinophil’s per HPF, consistent with esophinophilic esophagitis. FNA culture noted Actinomcyes Odontolyticus. Treatment was tailored for Penicillin-based therapy. On Hospital Day 12 , Repeat CT Chest did not identify a mediastinal collection or evidence of esophageal leak and noted resolving mural thickening of the esophagus.

DISCUSSION:
Thoracic actinomyces was diagnosed in the setting of active eosinophilic esophagitis. It is possible that EOE predisposes to Actinomyces as Actinomyces is a commensal flora of GI tract and this could have spread to mediastinum directly due to barrier injury. Increasing availability of endoscopic modalities may provide more accessible diagnostic options, which will help in targeted treatment. We report a possible association of EOE and Actinomyces and also successful minimally invasive diagnosis of actinomyces in a difficult anatomical location.
2154 In Situ Plastic Biliary Stents Causing Intestinal Perforation: A Case Series
Authors: Thapa Namisha , Loudin Michael , Sharzehi Kaveh , De Melo Silvio , Enestvedt Brintha 
Published: October 2019

INTRODUCTION:
Intestinal perforation is a rare complication of plastic biliary stents which exclusively occurs in the setting of preceding stent migration. We present the first case series to our knowledge of four patients with intestinal perforation from non-migrated in-situ plastic biliary stents.

CASE DESCRIPTION/METHODS:
1: A 65-year-old-woman with biliary stent placement for cholangiocarcinoma-related obstruction presented with acute right upper quadrant (RUQ) pain. She had tachycardia, RUQ tenderness, and elevated liver function tests (LFT). CT scan showed duodenal perforation, and on ERCP a stent was seen perforating through the opposite duodenal wall. Prior straight 10Frx12 cm plastic stent was exchanged for a similar stent with a full external pigtail and a ½ internal pigtail. Over the scope clip was used to close the defect. 2: A 69-year-old-man with biliary stent placement for malignancy-related biliary stricture presented with acute RUQ pain. He had tachycardia, RUQ tenderness, and leukocytosis. CT scan showed duodenal perforation from distal tip of biliary stent with proximal aspect still in the common bile duct (CBD) though ERCP showed no obvious defect. Prior straight 10Frx10 cm plastic stent was exchanged for a similar stent with a full external pigtail and a ¾ internal pigtail. 3: A 60-year-old man with metastatic colorectal carcinoma of the liver with hepatic arterial infusion pump associated biliary sclerosis and stent placement presented with acute RUQ pain. He had leukocytosis, RUQ tenderness, and an acute LFT elevation. ERCP showed biliary stent causing duodenal wall ulceration. Prior 10 F × 12 cm plastic stent was replaced with a similar stent with a full external pigtail and ¾ internal pigtail. 4: A 24-year-old man with NASH cirrhosis status post orthotopic liver transplant and stent placement for anastomotic biliary stricture presented with acute LFT elevation. On ERCP, three plastic biliary stents were seen penetrating duodenal wall with proximal tips in place. Prior straight 10Frx12 cm plastic stents were replaced with similar stents with full external pigtail and a ¾ internal pigtail. An over the scope clip was used to close duodenal defect.

DISCUSSION:
Complication by in-situ plastic biliary stents may be decreased with full external pigtail stents. Stent exchange was successful in all cases, except case 4. This may have been due to the benign etiology of obstruction compared to malignant etiologies for others. An over the scope clip may be used successfully to close duodenal defect.
2156 Innovative Use of Linear EUS
Authors: Weinberger Jonathan , Grunwald Matthew , Waintraub Daniel J. , Ruggiero Maryanne , Rhee Rebecca , Mayer Ira , Khodorskiy Dmitriy O. 
Published: October 2019

INTRODUCTION:
Therapeutic echoendoscopic ultrasonography (EUS) is vital in the diagnosis, staging, and tissue acquisition of gastrointestinal (GI) malignancies. However, its use is typically limited to upper GI tract and rectum due to limited visualization and instrument length. We present a case of evaluating an extraluminal lesion adjacent to the distal small bowel, utilizing a linear echoendoscope.

CASE DESCRIPTION/METHODS:
65 year old male with a history of cecal perforation in the setting of ischemic colitis (no pathologic evidence of malignancy), status post right hemicolectomy, COPD, DM and CHF was admitted with right sided abdominal pain without change in bowel habits. CT scan revealed a mass in the mid abdomen. The mass appeared inseparable from the small bowel (ileum) just proximal to the ileocolic anastomosis; however, it was unclear if the mass was extraluminal or invading the lumen. Colonoscopy was performed and there was no evidence of an intraluminal mass. Interventional radiology was contacted for biopsy of the mass, however, there was no safe window for biopsy. GI was re-consulted and a decision was made to attempt an EUS with fine needle biopsy (FNB) in order to avoid diagnostic laparoscopy. Ileum was intubated with a pediatric colonoscope and a 0.035 inch guidewire was advanced into the small bowel. Two endoclips were placed proximal to the ileocolic anastomosis for fluoroscopic guidance. The colonoscope was then exchanged for a linear echoendoscope which was advanced alongside the guidewire with an inflated forward balloon using endoscopic and fluoroscopic guidance. The mass was identified and FNB was performed. Cytology revealed atypical lymphoid cells consistent with high grade diffuse large B cell lymphoma.

DISCUSSION:
Linear echoendoscope is often used for evaluation of distal colonic lesions. Traditionally the miniprobe is used for diagnosis of lesions not reachable with a linear endoscope, but lacks the ability for tissue acquisition. Recently, a forward viewing echoendoscope has been developed however it is not yet widely available. We describe a case of an innovative use of linear echoendoscope in the proximal colon/distal small bowel, sparing a more invasive surgical procedure. In addition, we describe a novel use a forward balloon as a safety mechanism for advancing a side viewing endoscope in areas of limited visualization.
2162 Cryotherapy for Management of Transfusion-Dependent Gastrointestinal Hemorrhage Secondary to Gastric Antral Vascular Ectasia
Authors: Hanada Yuri , Wang Kenneth K. 
Published: October 2019

INTRODUCTION:
Non-variceal upper gastrointestinal hemorrhage is traditionally managed with mechanical devices, thermal coagulation, or injection therapy. However, due to specific lesion characteristics, certain cases may not be easily or effectively managed by these methods, in which case either a novel therapy or repurposing of an existing technique could be considered. Here, we present a case of gastric antral vascular ectasia (GAVE) addressed with cryotherapy.

CASE DESCRIPTION/METHODS:
An 82 year old man with CAD s/p CABG, AS s/p AVR, symptomatic AVB s/p PPM, HTN, and BPH presented to his primary care provider Clinic with chronic, symptomatic, transfusion-dependent iron-deficiency anemia with a hemoglobin nadir of 6.7 g/dL from 12.2 g/dL four months prior. The patient also reported possible melena, though stool appearance was obscured by oral iron supplementation. He underwent diagnostic EGD, which identified severe GAVE with mild associated bleeding throughout the entire stomach. This was therapeutically managed with APC, but given the severity and diffuse nature of the GAVE (Figure 1), the patient was referred for cryotherapy. Medically, the patient was recommended to initiate PPI therapy and continue iron supplementation. Three sessions occurring at 1 month intervals were completed, followed by one session 3 months out. By the third session, the patient no longer required transfusional support to maintain appropriate hemoglobin levels. On endoscopic follow-up 6 months out (one year from initial EGD), the GAVE had improved in severity (Figure 2).

DISCUSSION:
The current treatment of GAVE primarily involves argon plasma coagulation, which is limited by its inability to treat large areas of mucosa in an efficient manner. However, data supporting the use of cryotherapy as a safe and effective treatment for GAVE are emerging. Patients with diffuse, extensive mucosal gastrointestinal lesions should be referred to a tertiary care center to assess cryotherapy candidacy.
2163 Successful Endoscopic Mucosal Resection for Duodenal Neuroendocrine Tumor: To Net a NET
Authors: Dharmadhikari Neal D. , Gao Tian , Yilmaz Osman , Shah Samir A. 
Published: October 2019

INTRODUCTION:
Neuroendocrine tumors (NET) are rare (0.49 % of all malignancies) and slow-growing that can arise anywhere in the body from neuroendocrine cells. They are most commonly seen in the gastrointestinal tract, but compromise <2% of all gastrointestinal malignancies. NETs in the duodenum are even less common as they make up 2.6 % of all NETs. This case illustrates the appropriate diagnosis and management of a rare gastrointestinal malignancy – duodenal NET. Endoscopic mucosal resection (EMR) has become more common for the management of duodenal NETs, but guidelines are still evolving.

CASE DESCRIPTION/METHODS:
A 79-year-old male with a medical history of prostate cancer, stage 3 chronic kidney disease, gastroesophageal reflux disease with occasional dysphagia underwent an upper endoscopy which revealed a benign Schatzki ring that was dilated. A single 7 mm shiny nodule in the duodenal bulb was biopsied revealing a grade 1 NET. Endoscopic ultrasound (EUS) to assess showed the lesion measured 4.4 mm in thickness and 6 mm in diameter, originate within the submucosa and there was no surrounding lymphadenopathy. The lesion was raised by injecting it with a solution of epinephrine and methylene blue. A ligation-assisted endoscopic mucosal resection was completed. Pathology noted a well-differentiated grade 1 NET measuring 6 mm involving the submucosa and mucosa with no malignant cells noted in the margins. He returned home without any complications.

DISCUSSION:
The diagnosis of neuroendocrine tumors is difficult given their rarity, size, and potential asymptomatic presentation. For small, non-functional, localized duodenal NETs, resection is the goal and endoscopic therapy is becoming the preferred method of resection. Numerous surgical and endoscopic techniques have been explored; however, the optimal method has yet to be determined. This case shows the successful use of EMR after EUS evaluation in treating a duodenal NET with evidence of clean margins on pathology. We were able to describe a rarely encountered tumor and highlight the evolving use of advanced endoscopy in its management. Clinicians should be suspicious for NETs when encountering a shiny-appearing nodule in the gastrointestinal tract.
2165 Endoscopic Ultrasound-Guided Fine-Needle Biopsy (FNB) of a Liver Lesion Demonstrating Metastatic Esophageal Adenocarcinoma
Authors: Stadmeyer Peter , Akhter Ahmed , Barksdale Byron , Matkowskyj Kristina , Gopal Deepak 
Published: October 2019

INTRODUCTION:
The role of biopsy in determining the etiology of hepatic lesions is crucial in determining pathology and potential therapy. Liver biopsies are often accomplished with the aid of interventional radiology with a percutaneous approach. However, there are instances when a percutaneous approach is not feasible. Here, we present a patient who underwent an endoscopic ultrasound (EUS)-guided fine needle biopsy (FNB) of a left lobe hepatic lesion which demonstrated metastatic esophageal adenocarcinoma.

CASE DESCRIPTION/METHODS:
A 76 year-old man with a history of esophageal adenocarcinoma, who previously underwent treatment with neoadjuvant chemoradiation and surgical resection 3 years earlier, was found on routine surveillance CT imaging to have a lesion within the left lobe of his liver. He subsequently underwent a PET CT that demonstrated this lesion to be FDG avid without any other evidence of FDG avidity (Figure 1). Interventional radiology was initially consulted for liver biopsy, however due to a poor window for access this could not be performed. He subsequently was referred for an EUS-guided FNB. EUS demonstrated a round to oval shaped, irregular mass within the left lobe of the liver. The mass was hypoechoic and heterogeneous with central spiculation. The mass measured 43 mm by 33 mm in maximal cross-sectional diameter. Color Doppler imaging was used prior to needle puncture to confirm a lack of significant vascular structures within the needle path. Fine needle aspiration for cytology was performed. Three passes were made with a 22-gauge FNB needle (Acquire™ 22ga) using a trans-gastric approach (1 pass for cytology touch prep, and 2 core biopsy samples for surgical pathology) (Figure 2). Preliminary rapid on-site cytological evaluation (ROSE) was suspicious for malignancy, with final specimen demonstrating adenocarcinoma. Surgical pathology from the core biopsy was reviewed and a diagnosis of metastatic adenocarcinoma, moderately differentiated, morphologically compatible with esophageal adenocarcinoma was rendered (Figure 3).

DISCUSSION:
This case demonstrates the utility and feasibility of an EUS-guided liver biopsy when a percutaneous approach is not possible to help make a diagnosis and direct therapy.
2166 Delayed Symptomatic Pneumoperitoneum After Peroral Endoscopic Myotomy (POEM)
Authors: McGrath Brian , Chen Huimin , Xia Liang , Chen Xiangbo , Abdelfatah Mohamed Magdy , Keilin Steven , Cai Qiang 
Published: October 2019

INTRODUCTION:
Per-oral endoscopic myotomy (POEM) is as an effective and safe option for the treatment of achalasia. Symptomatic pneumoperitoneum, one of the most significant adverse events noted with POEM, generally presents during the periprocedural period and is treated with needle decompression. We report two cases of delayed symptomatic pneumoperitoneum that were recognized more than 24 hours after POEM, which has not been reported previously.

CASE DESCRIPTION/METHODS:
A 49-year-old female with history of achalasia presented with two-year history of dysphagia, 40lb weight loss, regurgitation, and chest pain that had been refractory to multiple esophageal dilations and botulinum toxin injections. She underwent an uncomplicated POEM and was admitted for observation. On post-procedure day 2, she complained of worsening shortness of breath and abdominal pain. Chest and abdominal radiographs revealed large volume pneumoperitoneum. Due to continued progression of pain and dyspnea, as well as persistence of pneumoperitoneum on imaging, she underwent CT-guided FNA decompression on post-procedure day 4, with 660 ml of air evacuated and improvement of pain and dyspnea. A 53-year-old female with history of achalasia presented with four-month history of dysphagia, 40lb weight loss, and regurgitation. She underwent an uncomplicated POEM and was admitted for observation. Approximately four hours after the procedure, she became febrile and tachycardic, concerning for perforation. She was transferred to the ICU, where physical exam revealed crepitus to the neck and chest, as well as diffuse abdominal tenderness without guarding or rebound. A chest radiograph revealed large volume pneumoperitoneum. Gastrograffin swallow showed no evidence of contrast extravasation or perforation. On post-procedure day 1, she underwent bedside ultrasound-guided needle decompression using a 16-gauge angiocatheter, which led to a rush of air and improvement in abdominal pain.

DISCUSSION:
While symptomatic pneumoperitoneum is the second most common adverse event associated with POEM, it has been reported exclusively in the immediate periprocedural period. The etiology of delayed symptomatic pneumoperitoneum in these cases is unclear. No precipitating factors were identified in the first case; in the second case, it is possible that the symptoms were due to a microperforation not detected on imaging. These cases illustrate the importance of continued vigilance for this complication outside of the immediate periprocedural period.
2174 Endoscopic Retrograde Cholangiopancreatography Leading to Necrotizing Fasciitis: A Case Report
Authors: Nasir Umair M. , Panchal Dayna , Choi Catherine , Ahmed Ahmed , Rodgers Brandon , Kutner Matthew 
Published: October 2019

INTRODUCTION:
Endoscopic Retrograde Cholangiopancreatography (ERCP) had become the favored method to access the pancreaticobiliary system because its a safer less invasive method compared to surgery. However, as with any procedure ERCP comes with its own risks and potential complications. We present a unique case of patient who underwent and ERCP and developed necrotizing infection of neck and a submandibular abscess.

CASE DESCRIPTION/METHODS:
Patient is a 66-year-old female who presented to an outside hospital with complaint of right upper quadrant abdominal pain, workup revealed choledocholithiasis. ERCP was attempted however cannulation was unsuccessful. The patient was discharged home after the procedure, but within 48 hours she presented to our institution complaining of left sided neck pain, dysphagia, and drooling. Computed tomography of the neck revealed extensive gas and fluid collections at the left submandibular space. Patient was taken to the operating room for drainage of left deep neck abscess. Drainage and irrigation of the abscess yielded streptococcus mitis. Rest of patient’s hospital course was uncomplicated and patient was discharged with appropriate follow up.

DISCUSSION:
ERPC is a challenging gastrointestinal endoscopic procedures. Adequate volume of procedures is required to maintain proficiency and avoid complications. Uncommon complications such as perforation are reported in <1% of case. Perforations are most commonly reported in the esophagus, stomach, duodenum, periampullary region, and bile ducts. In the case of our patient, ERCP was complicated by a perforations of the hypopharynx. The most frequent cause of pharyngeal perforation is iatrogenic due to instrumentation commonly due to the advancement of the endoscope or endotracheal tube (ETT). Pharyngeal perforation can be subclassified into supraglottic and infraglottic. The latter is more commonly associated with advancement of an ETT during intubation and presents with blood in the ETT or decreased end tidal CO2 or decreased tidal volume. Advancement of endoscope in an already intubated patient can lead to a supraglottic tear which can present with bleeding observed outside of the ETT. Patients with supraglottic or infraglottic perforations can present with similar clinical symptoms of dysphagia, fevers, oral bleeding, subcutaneous emphysema of the neck. Quick identification and treatment can decrease the morbidity and mortality in such patients.
2180 Why Is This Hemoperitoneum Orange? A Late Diagnosed Isolated Rupture of the Gallbladder Secondary to Blunt Abdominal Trauma
Authors: Alansari Tarek H. , Alansari Ahmed , Vareedayah Ashley , Tzimas Demetrios , Harley Jennifer 
Published: October 2019

INTRODUCTION:
The gallbladder is protected from blunt trauma by its unique anatomic position inferior to the liver and behind the rib cage. Biliary tree injuries are rare, occurring in approximately 2% of cases of blunt trauma. Isolated gallbladder injury is even rarer and the exact incidence is unknown.

CASE DESCRIPTION/METHODS:
48 year old male with a history of alcohol abuse who was brought to the Emergency Department with right upper quadrant pain after falling over a fan. Labs showed stable chronic macrocytic anemia and elevated liver function tests. CT revealed ascitic fluid with suspected hemoperitoneum. Surgery managed the patient conservatively in light of stable serial hemoglobin values. Over the next 4 days, the patient developed shock with multi-organ failure. Primary team presumed deteriorating clinical status was related to alcoholic hepatitis and acute on chronic liver failure. Gastroenterology was then consulted and we recommended urgent diagnostic paracentesis. When smeared, the fluid was dark orange in color. A Medicine resident called the GI fellow and asked “why is this hemoperitoneum orange?” Ascitic bilirubin was 25 mg/dL. Surgery believed it was due to hemolysis of the hemoperitoneum. We transferred the patient for urgent ERCP that revealed external accumulation of contrast and bubbles in proximity to the gallbladder. A common bile duct stent was placed. Patient was taken for exploratory laparoscopy where a 5 cm defect on the anterior wall of gallbladder was noted and cholecystectomy was performed. Postoperative course was complicated by a 9 × 7 cm intra abdominal abscess. The collection was not amenable to Interventional Radiology drainage due to its proximity to the spleen. The patient underwent successful endoscopic cystogastrostomy with placement of a lumen apposing metal stent.

DISCUSSION:
Isolated gallbladder injury remains challenging to diagnose both clinically and radiologically. When suspected, percutaneous drainage is indicated to establish diagnosis even if radiological investigations are unrevealing. There is a high risk of morbidity and mortality secondary to a missed or delayed diagnosis. For patients in whom diagnosis is delayed, abdominal sepsis secondary to non-sterile biliary peritonitis can complicate the postoperative course. ERCP can be performed prior to surgery to reduce the pressure gradient between the biliary system and the duodenum allowing bile to drain preferentially into the duodenum.