bluuebunny/crossref_metadata_2025_split huggingface dataset:
2194 Prevention of Excessive Gas Accumulation With a Biliary Dilation Balloon During Endoscopic Cryotherapy
Authors: Abadir Alexander , Clary Meredith , Samarasena Jason , Chang Kenneth J. 
Published: October 2019

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

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

DISCUSSION:
Gas by-products are produced during cryotherapy, which in the case of a patient with a Roux-en-Y, causes substantial risk for perforation. With a distally inflated biliary dilation balloon, gas is prevented from accumulating in the small intestine where it may be difficult to suction, reducing the risk of perforation. This technique may be applied to similar cases where perforation risk is elevated.
2195 Expanding Therapeutic Options for Ileocecal Valve and Rectal Strictures With Lumen-Apposing Fully Covered Metal Stents
Authors: Vachaparambil Cicily , Abdelfatah Mohamed Magdy , Chawla Saurabh , Willingham Field , Mekaroonkamol Parit 
Published: October 2019

INTRODUCTION:
Radiation-induced and Crohn’s-related colonic strictures are debilitating conditions requiring intensive serial endoscopic dilations or surgery. Use of colonic stents in benign strictures are limited by migration risk, lack of removability, and technical difficulties in placement. This is especially true of ileocecal valve (ICV) strictures given the anatomically challenging location and short stents are preferred. We report the cases of an ICV and distal rectal stricture, refractory to endoscopic dilation, that underwent successful lumen apposing fully covered metal stent (LAMS) placement.

CASE DESCRIPTION/METHODS:
A 32-year-old African American male with a history of Crohn’s disease complicated by ICV stenosis causing recurrent partial small bowel obstruction, was admitted with worsening nausea, vomiting, and abdominal pain. An abdominal CT showed dilated distal ileum to 4 cm with associated fecalization consistent with partial small bowel obstruction. A colonoscopy with balloon occlusion enterography confirmed a short <1 cm severe ICV stricture with non-inflamed colonic mucosa. He opted for an endoscopic dilation to 10 mm with good clinical response but this only lasted for 2 weeks. A stent placement was then performed using a 15 mm × 10 mm LAMS (Figure 1). His abdominal pain markedly improved with radiologic resolution of the small bowel obstruction. A 55-year-old African American female with a history of pelvic radiation for cervical cancer presented with tenesmus and alternating constipation and diarrhea. Barium enema and flexible sigmoidoscopy showed a focal rectal stricture at 10 cm proximal to the anal verge. She underwent serial endoscopic dilations up to 12-mm over a span of 6 months with no significant clinical response and the stricture kept recurring despite 2-3 week intervals between dilations. Ultimately, a 15 mm × 10 mm LAMS was placed (Figure 2). At 8-weeks, her tenesmus and post-constipation diarrhea were completely resolved.

DISCUSSION:
Our cases demonstrate the feasibility and efficacy of LAMS placement for refractory high-grade strictures even at anatomically challenging locations. LAMS was preferred here due to its removability and short length that could optimally fit in the ICV and distal rectum with an aim to minimize risk of stent migration due to its dumbbell configuration. However, the stricture site has to be reachable by a therapeutic gastroscope. Optimal duration for stent indwelling and risk of restenosis after stent removal remain unclear and warrant further study.
2196 A Case of Successful Endoscopic Management of Choledocholithiasis Complicated by Post-Transplant Biliary Stricture
Authors: Gollapudi Lakshmi Asritha , Kumar Anila , Bodin Roxana , Georgostathis Dimitrios , Lebovics Edward 
Published: October 2019

INTRODUCTION:
Post Liver transplant (LT) biliary stones, sludge and casts are a challenge to both advanced endoscopists and patients in the setting of complex anatomy, variable pathologies and multiple co-morbidities. The incidence rate of biliary stones is widely variable from 3.8%-18% and are associated with biliary strictures in roughly 90% of cases, increasing the complexity of the procedure. Here we are presenting a case of elevated liver enzymes and normal bilirubin in a LT patient with a history of post-LT biliary stricture.

CASE DESCRIPTION/METHODS:
70 year old male with past medical history of fulminant hepatic failure status post orthotopic LT complicated by biliary anastomotic stricture, presented for management of new onset elevated liver enzymes ten years post LT. At the time of presentation he denied any complains of abdominal pain, nausea, vomiting, fevers, or chills. He denied any new medications or herbal supplements. Afebrile and hemodynamically stable at presentation. Labs showed WBC- 6.3, AST-202, ALT-133, GGT-1368, ALP-439 Total Bilirubin – 0.8 (Normal), INR-1.06 and Tacrolimus level -2.4. Liver biopsy showed bile ductular reaction and sparse to mild portal inflammation with minor ductulitis and endothelialitis. Abdomen ultrasound showed common bile duct with biliary ductal dilatation which may represent stones or sludge. Patient underwent ERCP revealing a large 3 × 2 cm stone in the common hepatic duct proximal to the anastomotic stenosis with marked upstream biliary dilation. The stone was partially crushed with electrohydraulic lithotripsy (EHL) via Spyglass cholangioscopy. The stone fragments were removed using an extraction balloon. Two 10 Fr x 12 cm long angled plastic stents were placed in the right and left biliary systems. A repeat ERCP was performed 8 weeks later and EHL under spyglass was performed. The ducts were subsequently cleared and stenosis resolved.

DISCUSSION:
Biliary stones and sludge can occur at any time after LT, with a reported incidence of 5%–10%. Our patient presented 10 years post-LT with transaminitis and normal bilirubin. Yu et al reported biliary strictures and cold ischemia time were significantly associated with bile duct stone formation after liver transplantation in a case-control study. Hence we conclude that in following patients post LT who are on immunosuppressants, the physician needs to be vigilant as patients can have a late presentation which can lead to graft loss and increased morbidity and mortality.
2197 Successful EUS-Guided Treatment of Duodenal Varices With Coil Embolization
Authors: Cortez Nathaly , Mahfouz Mahmoud , Berzosa Manuel , Nasir Ahmad Basil 
Published: October 2019

INTRODUCTION:
Ectopic varices are unusual and can involve any site along the GI tract. Only 5% of variceal bleeding is related to ectopic varices such as duodenal varices. Ectopic variceal bleeding is usually massive, difficult to treat, and associated with high mortality rates. High clinical suspicion is warranted. No standardized treatment is recommended, and the management remains challenging with limited success in controlling recurrent bleeding. EUS-guided therapy has evolved as an effective therapeutic modality in gastric varices and this case demonstrates the role of EUS-guided coil embolization (EUS-CE) with cyanoacrylate (CYA) injection in the management of duodenal variceal bleeding.

CASE DESCRIPTION/METHODS:
81-year-old female with history of Diffuse large B cell lymphoma on chemotherapy presented with intermittent massive upper gastrointestinal bleeding. CT abdomen showed cirrhotic liver and portal vein thrombosis due to lymphoma involvement. Three endoscopies performed over a period of 5 days revealed 1 cm non-bleeding duodenal ulcer at the duodenal sweep without stigmata of recent bleeding. Due to recurrent bleeding, empiric coil embolization of the gastroduodenal artery and multiple duodenal branches through angiography was done by interventional radiology. However, severe bleeding recurred after the embolization, and the fourth urgent EGD showed large subepithelial violaceous lesions next to the deep penetrating ulcer, highly suspicious for duodenal varices. EGD-EUS confirmed these lesions were duodenal varices. By the fifth day of admission, patient had required 8 units of PRBC. Therefore, the decision was made to treat with EUS-CE. Two coils of 8 and 9 mm were deployed into the larger varix through a 19G EUS-FNA needle followed by 2 ml injection of CYA. A third 6 mm coil was also deployed in the feeder vessel also followed by CYA. Both lead to embolization and cessation of blood flow as demonstrated through Doppler investigation at the end of the procedure. Bleeding stopped and patient was discharged home to complete chemotherapy.

DISCUSSION:
Bleeding from duodenal varices require high suspicion as vessels could be miss if collapsed soon after bleeding. High clinical suspicion can result in early angiographic evaluation and intervention. Ideal management of ectopic variceal bleeding is still unclear. Multiple endoscopic technique modalities have been reported. EUS-CE with or without CYA injection is a safe endoscopic technique with effective variceal obliteration in most cases.
2199 Endoscopic Ultrasound-Guided Transrectal Drainage of a Tubo-Ovarian Abscess via a Lumen-Apposing Metal Stent
Authors: Shah Ruchit N. , West Sara , Sweeney Kaitlyn M. , Mehta Minesh , Diehl David L. 
Published: October 2019

INTRODUCTION:
Tubo-ovarian abscess (TOA) is a potentially lethal condition requiring a combination of medical and surgical intervention. Endoscopic ultrasound (EUS)-guided drainage is a known modality for safe and effective management of pelvic collections, but its role in TOA drainage is not well documented. We present a case of a TOA treated successfully with EUS-guided transrectal drainage using a lumen apposing metal stent (LAMS).

CASE DESCRIPTION/METHODS:
A 45-year-old woman presented to the hospital with a 4-day history of left lower quadrant abdominal pain. Her medical history included a right-sided TOA treated with antibiotics one year ago, type II diabetes mellitus, and obesity. She was tachycardic and tachypneic on arrival with a leukocytosis and elevated inflammatory markers. Computed tomography (CT) revealed a 11.3 × 10.3 × 9.4 cm complex cystic structure within the left adnexa consistent with a TOA (Image 1). Due to worsening leukocytosis and abdominal pain, interventional radiology was consulted but could not find a safe window for percutaneous drainage. A rectal EUS subsequently revealed a 50 × 45 mm abscess 20 cm from the anal verge (Image 2). A 19-gauge EZ-Shot 3 FNA needle was advanced with return of purulent fluid. After injection of 15 cc ionic contrast to delineate the abscess and confirm positioning, EUS-guided transrectal drainage of the TOA with placement of a 15 × 10 mm AXIOS stent (Boston Scientific, Marlborough, MA, USA) was successfully performed. The distal flange was deployed within the abscess cavity and the proximal flange was deployed within the rectal lumen with copious amounts of purulent drainage through the AXIOS stent (Image 3). Repeat CT performed one week later revealed significant interval decrease in the size of the TOA.

DISCUSSION:
EUS-guided drainage of pelvic collections has been established as a lower-risk alternative to surgical interventions, especially for collections greater than 4 cm and within a 1-2 cm reach of the EUS transducer. Furthermore, use of LAMS can facilitate drainage through a wider conduit, promoting rapid evacuation and source control. To our knowledge, this is the first reported case of successful EUS-guided transrectal drainage of a TOA using a LAMS.
2201 Innovative Endoscopic Management of a Bariatric Surgery Complication
Authors: Herman Michael , Kakked Gaurav , Collins Kelsey , McCabe Evin , Kasmin Franklin 
Published: October 2019

INTRODUCTION:
Vertical Banded gastroplasty (VBG) is a purely restrictive bariatric surgery that was the predominant weight loss procedure in the 1980s. The following case describes a well-known complication of VBG that was managed with an innovative endoscopic technique.

CASE DESCRIPTION/METHODS:
A 56-year-old lady with a history of open VBG 18 years ago presented with several years of recurrent vomiting, heartburn, and excessive weight loss. An upper GI series revealed a large distend proximal gastric pouch above the mesh with severe stasis that produced a mass effect and resultant compression of the rest of the stomach. She was offered a conversion to Roux en y gastric bypass, however she declined. She was subsequently referred to a GI for further evaluation and potential endoscopic intervention. An Upper GI endoscopy was performed, which revealed mild esophagitis, evidence of vertical banded gastroplasty, and gastric pouch distention with copious amount of food debris. The lumen through the band was identified and was noted to be very narrowed and was not easily traversable with the upper endoscope. Therefore, a decision was made to perform an EUS guided gastro-gastrostomy with placement of a lumen opposing metal stent. The distal pouch was punctured under EUS guidance and a 15 × 10 mm AXIOS Stent was deployed adjacent to the previously placed band, creating a larger lumen for food content to pass. The stent was serially dilated to 18 mm using a through the scope (TTS) dilator. Contrast injected proximally was seen to flow freely from the gastric pouch into the antrum and the duodenum through the stent. Patient had an uneventful post-procedure course and was discharged the next day. She later reported significant improvement in reflux symptoms, gained 15 pounds, and was more than elated.

DISCUSSION:
VBG quickly gained popularity in the 1980s because it was the only bariatric surgery that did not have malabsorptive side effects. Over time, however, patients began experiencing post procedural nausea, vomiting, and heartburn from pouch dilatation, band erosion, staple line disruption, marginal ulceration, and is now rarely used as a bariatric surgical option. The versatility of endoscopic stents have made them useful in the management of many bariatric surgical complications, including fistulas, leaks, obstructions, strictures, and stenoses. To our knowledge, this was the first case of severely symptomatic pouch dilatation following VBG that was successfully managed endoscopically.
2202  Liver Mass in Cirrhotic Patients: Is It Always Hepatocellular Carcinoma (HCC)?
Authors: Hayat Maham , Zia Hassaan , Hayat Muhammad Hashim , Fazili Javid 
Published: October 2019

INTRODUCTION:
Pancreatic acinar cell carcinomas (PACCs) comprise only 1-2% of all pancreatic cancers. Patients with PACC have a prognosis better than pancreatic ductal adenocarcinomas but worse than pancreatic neuroendocrine tumors. They are easier to differentiate from the prior, but may have many similar morphological features to the latter. The majority of pancreatic tumors are adenocarcinomas of the ductal type; and carcinomas with multiple lineage differentiation are extremely rare. We present a rare case of PACC with neuroendocrine differentiation.

CASE DESCRIPTION/METHODS:
51-year-old male with history of chronic Hepatitis B infection, liver cirrhosis (CPT class B, MELD 15) was admitted for abdominal pain, leg swelling and worsening renal function. Pertinent physical exam revealed a tense abdomen and diffuse tenderness. An abdominal non-contrast computed tomography (CT) scan revealed a large cm ill-defined mass in the central liver involving both right and left liver lobes. A large mass medial to the splenic hilum measuring approximately 8.7 × 6.8 cm, abutting the stomach, pancreas and spleen was also seen. An Endoscopic Ultrasound (EUS) confirmed an anechoic splenic hilum mass measuring 8 cm in greatest dimension. A 2.4 cm × 2.2 cm anechoic left liver lobe mass was also appreciated. Fine needle aspiration (FNA) was performed for each of these masses. Histopathology revealed acinar-cell carcinoma with neuroendocrine differentiation. Positive Periodic acid-Schiff (PAS), Trypsin and Chromotrypsin stains on immunohistochemistry (IHC) supported the acinar differentiation. Positive synaptophysin and chromogranin stains supported neuroendocrine differentiation. Diagnosis of pancreatic neoplasm with metastasis to the liver was made and patient was referred to an oncologist.

DISCUSSION:
Forming the diagnosis of a mixed carcinoma requires thorough assessment of individual components in the tumor. Current theories suggest their origin from a stem cell with propensity for multi-directional differentiation. Close morphological examination and immunohistochemical staining are fundamental in making an accurate diagnosis. Better understanding of prognosis and treatment of pancreatic tumor with multi-lineage origin requires evaluation of additional cases due to their paucity.
2204 Non-Hepatic Hyperammonemia Associated With Acute Bowel Perforation
Authors: Melnyk Janet L. , Cavaliere Kimberly R. , Roth Nitzan C. 
Published: October 2019

INTRODUCTION:
Hyperammonemia is often caused by impaired ammonia degradation in patients with cirrhosis or acute liver failure and can lead to acute mental status changes known as hepatic encephalopathy. Rarely, elevated ammonia levels occur in patients without liver disease. We report a case of non-hepatic hyperammonemia in a critically ill patient who was found to have bowel perforation.

CASE DESCRIPTION/METHODS:
A 62-year-old man with history of coronary artery disease and chronic systolic heart failure presented with chest pain and shortness of breath. He was found to have methicillin-sensitive Staphylococcus aureus bacteremia complicated by infective endocarditis requiring aortic valve replacement performed on hospital day (HD) 24. Post-operative course was complicated by altered mental status on HD 38. He later developed septic shock requiring pressor support and mechanical ventilation. Sedation was discontinued, but he remained unresponsive to verbal or noxious stimuli, a departure from a normal mental status a few days prior. Workup was significant for an elevated venous ammonia level of 118 umol/L on HD 48. Other than mildly elevated alkaline phosphatase 149 U/L and INR 1.66, his liver tests were within normal limits. Earlier in the admission, non-contrast CT showed hepatic steatosis with normal liver morphology and no features of cirrhosis or portal hypertension. Trial of therapy with rifaximin and lactulose HD 48-69 provided no benefit. On HD 52, the patient’s serum ammonia had increased to 231 umol/L, and his abdomen was found to be acutely distended and rigid with serum lactate 4.1 mmol/L. Repeat CT showed intraperitoneal free air, pneumatosis, and mesenteric venous gas. Emergent exploratory laparotomy revealed a perforated ascending colon, and hemicolectomy was performed. Post-surgery, serum ammonia levels normalized however the patient’s mental status did not improve. He was terminally extubated and expired HD 69.

DISCUSSION:
We present a unique case of non-hepatic hyperammonemia that preceded the discovery of acute bowel perforation, with serum ammonia levels normalizing after the damaged bowel was surgically removed. No other known causes of hyperammonemia were identified, particularly liver disfunction, ammonia-raising medications, infection with urease-producing organisms. Hyperammonemia has been shown to be associated with gastrointestinal hemorrhage, however that was not the case with this patient. Perforated viscus should be considered when non-hepatic hyperammonemia is encountered.
2208 Autoinflammation in an Immunocompromised Lymphoma Patient With Sepsis
Authors: Kraus Fabian B. T. , Mehta Amit , Wan David 
Published: October 2019

INTRODUCTION:
Hemophagocytic lymphohistiocytosis (HLH) is a rare autoinflammatory, typically pediatric condition, often triggered by infectious or malignant diseases in the immunocompromised patient. In this case, we describe the coincidence of HLH and bacterial sepsis in an adult NK/T cell lymphoma (NKTCL) patient.

CASE DESCRIPTION/METHODS:
A 38-year-old man presented with weight loss, fevers, night sweats and jaundice. Dermatological findings, including petechiae on the chest and extremities as well as an oropharyngeal soft palate erosion, were biopsied and revealed extranodal small cell NKTCL. Treatment was initiated according to the SMILE protocol yet soon complicated by fever and hypotension, which made an empiric antibiotic therapy with meropenem and amikacin necessary. Initial blood tests showed transaminitis, an acute drop in hemoglobin and thrombocytopenia. This, in combination with progressive hypotension and abdominal pain, raised suspicions of an acute GI bleed, but an esophagogastroduodenoscopy was unremarkable. Abdominal ultrasound, chest X-ray and abdominal CT, also yielded no evidence for bleeding, but confirmed the disease’s progression and led to treatment expansion by pembrolizumab. An increased EBV load, hypofibrinogenemia, hypertriglyceridemia, lactic acidosis and elevated ferritin levels in combination with the described clinical findings finally led to the diagnosis of HLH, complicated by disseminated intravascular coagulopathy (DIC), and were treated with steroids and plasma products. In the days thereafter, the patient’s fever spiked to 39.8°C and abdominal pain increased. Blood cultures were positive for MRSA and an infection with Parainfluenza virus was diagnosed. Anti-infectious treatment was adjusted accordingly. Decompensating electrolyte disturbances due to renal failure tachycardia and hypotension required catecholamine-treatment and the patient was transferred to the ICU where he deceased six days after initial admission.

DISCUSSION:
The complexity of the phenotypical diagnosis as well as the current lack of time-tested therapeutics pose major challenges in the treatment of HLH. Here we describe the history and death of a NKTCL patient, whose diagnosis and treatment was complicated by DIC and bacterial sepsis. We want to highlight the importance of a quick diagnosis and the rapid treatment of HLH. Further research is needed to advance diagnostic tools, optimize current therapeutic approaches and prevent comorbidities.