bluuebunny/crossref_metadata_2025_split huggingface dataset:
2173 Successful Endoscopic Drainage of Intraperitoneal Hematoma Using Lumen Opposing Fully Covered Metal Stent and Intracavitatory Thrombolytics
Authors: Olivier Sarah , Gollapudi Lakshmi Asritha , Tewari Virendra 
Published: October 2019

INTRODUCTION:
Incompletely drained intraperitoneal collections represent a therapeutic challenge. Interventional radiologists and surgeons have employed adjunctive intracavitary fibrinolytic agents to break down collections, however it has not been employed endoscopically to the best of our knowledge. We present a case of an intraperitoneal hematoma in a patient which was successfully drained endoscopically using thrombolytics.

CASE DESCRIPTION/METHODS:
A 16 year old male with past medical history of idiopathic thrombocytopenic purpura presented to our hospital with complains of left upper quadrant abdominal pain, radiating to the back for four days prior to the presentation. He also reported a blunt trauma to the upper abdomen two months prior to the presentation. Abdominal examination revealed tenderness to palpation in LUQ, with no guarding or rigidity and normal bowel sounds. Laboratory values at the time of presentation were within normal limits. Upper endoscopy and Colonoscopy were performed. Upper endoscopy revealed mild erosive gastritis. Colonoscopy was normal. He underwent Computed Tomography (CT) of abdomen and pelvis with contrast, revealing a 5 × 6 × 6.7 cm mass likely a hematoma abutting the spleen, pancreas and left kidneys. Hospital course complicated by fever and leukocytosis. Transgastric drainage of hematoma was performed by Endoscopic Ultrasound (EUS) using fully covered lumen opposing 1.5 cm wide and 1 cm long stent placement with initial drainage of purulent material. Two additional EGDs needed over subsequent two weeks to address one episode of fever with unchanged collection size and thick internal debris. First washout was done with 2000cc of Normal Saline, 500cc of Gentamicin, and 4 mg of Alteplase. During the second washout, we instilled 4 mg of Alteplase and 5 mg DNAse in 60 ml saline with occlusion technique for 10 minutes and subsequent drainage. Patient was discharged and was symptom free. CT scan performed at 8 weeks post placement showed complete drainage of hematoma and stent was removed. Patient is pain free and doing well after that.

DISCUSSION:
The use of fibrinolytics in endoscopic drainage of intraabdominal effusions has not been explored. In our case the use of fibrinolytics facilitated the dissolution of thick internal debris resulting in complete resolution of the collection. In conclusion, adjunctive use of tPA and DNAse along with EUS guided drainage appears to be safe and effective to dissolve thick internal debris avoiding the need for surgical intervention.
2176 An Old Friend in a New Neighborhood: The Presentation and Management of Intraductal Hepatocellular Carcinoma
Authors: Beard Jasna I. , Philips George 
Published: October 2019

INTRODUCTION:
Hepatocellular carcinoma (HCC) remains one of the most commonly addressed issues by gastroenterologists and tops the differential list for many liver lesions. However, this common disease can find rare ways to surprise even the very experienced, as occurred in the case of our 32 year old patient admitted for ascending cholangitis, later deemed secondary to intraductal invasion of hepatocellular carcinoma with a right lobe mass. Prognosis is generally better if a parenchymal mass is present. Isolated intraductal HCC is considered a third separate entity from HCC and cholangiocarcinoma with the suspicion that it arises either from intermediate cell line with features of both or as a concurrent "double-primary" malignancy. Both entities are uncommon processes with varied approaches to management of biliary obstruction. With exception of those transplanted, the management is palliative and generally focused on debulking and sometimes biliary stenting. We approached our case differently, opting for intraductal RFA as a palliative measure alongside chemoembolization of the primary mass.

CASE DESCRIPTION/METHODS:
A 32-year-old male with non-cirrhotic chronic hepatitis B presented with epigastric pain, vomiting, and serologic features of ascending cholangitis. Total bilirubin was 16.8 mg/dL, alpha fetoprotein 114 ng/mL, cancer antigen 19-9 1.0 U/mL. Imaging raised concern for HCC versus cholangiocarcinoma and he underwent percutaneous biopsy confirming moderately differentiated HCC. Magnetic resonance imaging raised concern for bile duct luminal irregularities. Endoscopic retrograde cholangiography that followed showed multifocal stenoses of a dilated biliary system and cholangioscopy was used to biopsy a polypoid mass near the biliary bifurcation. Pathology showed HCC. Endobiliary radiofrequency ablation was then employed endoscopically to ablate the intraductal lesions. Subsequent bilirubin 22 days later was 1.8 mg/dL. He suffered no complications related to intraductal RFA and experienced notable clinical improvement.

DISCUSSION:
While few cases are known and even fewer published, most intraductal HCC is diagnosed by percutaneous biopsy, exam of explant, or post-mortem. To our knowledge, this is the first described case demonstrating reliable diagnosis of intraductal HCC by single operator cholangioscopic biopsy and subsequent treatment with endobiliary RFA, highlighting the exciting potential of new technology used to treat an atypically presenting commonly encountered condition.
2177 Endoscopy-Directed Overtube-Assisted Vacuum Therapy of a Colo-Rectal Anastomotic Leak
Authors: Dukes Seth , Pinson Ross , Hawkins Jack , Cho Ryan 
Published: October 2019

INTRODUCTION:
Colorectal anastomotic leak is a feared and potentially catastrophic complication of colorectal surgery. It presents an increase morbidity and mortality risk, hospital stays, cost and potential for repeat procedures. We present a case of development of an anastomotic leak managed with an overtube-assisted endoscopic vacuum therapy (EVT) under direct endoscopic visualization.

CASE DESCRIPTION/METHODS:
51 year old woman with a rectal cancer status post neoadjuvant therapy, low anterior resection (7 cm from the anal verge) and diverting loop ileostomy presented with a complaint of abdominal pain at 3 weeks post-op. A gastrograffin enema revealed contrast extravasation into the pre-sacral space confirming a colorectal anastomotic leak. The endoscopic exam revealed dehiscence of an end-to-end anastomosis at 7 cm from the anal verge, with a 2-cm defect that led to the pre-sacral cavity, measuring 6 × 4 cm in size. A polyurethane sponge was cut to the dimension of the cavity and sutured to a 16-Fr NG tube. A short overtube was placed into the opening of the cavity. The sponge was advanced through the overtube, under direct visualization, with a scope behind it. The tube was connected to a vacuum system for continued negative pressure at 175 mmHg. The procedure was repeated at a three-day interval. Over 7 sessions, the primary defect was completely sealed, reduced to 10% with diffuse granulation tissue formation. Serial barium enemas following treatment showed no evidence of extravasation or concern for persistent leak. On subsequent takedown of the ileostomy the patient was able achieve normal bowel function.

DISCUSSION:
Endoscopic treatment of anastomotic leaks has been proposed as an alternative to operative management in clinically stable patients with non-generalized peritonitis. Modalities include SEMS, pigtail stent placement and EVT . EVT was first described in 2008, which is proven to heal mucosal defects are placed at repeat intervals to allow for slow closure of the defect, with a higher success rate of 79% compared to other endoscopic modalities. No delivery system currently exists here in the states, allowing for the ease deployment of the sponge device. This case demonstrate that a short overtube (typically used for foreign body removal) can be used as a deployment device and highlights this unique way of advancing the sponge into the cavity using the scope as a pusher, allowing for direct visualization of the deployment.
2184 The First Case of Endoscopic Ultrasound Guided Liver Biopsy Followed by Endoscopic Sleeve Gastroplasty in the Same Session
Authors: Reja Debashis , Shahid Haroon , Tyberg Amy , Kahaleh Michel , Sarkar Avik 
Published: October 2019

INTRODUCTION:
Endoscopic sleeve gastroplasty (ESG) is a novel procedure that is safe and effective for weight loss that has been shown to have significantly less morbidity than alternative bariatric procedures. We present the first case of Endoscopic ultrasound-guided liver biopsy (EUS-LB) done in the same session as ESG. Both procedures were without complications, and were technically and clinically successful.

CASE DESCRIPTION/METHODS:
28 year old female with hypertension and morbid obesity presented for elevated liver function tests concerning for NAFLD. In past 20 months patient went from 268 to 293 pounds and failed lifestyle interventions. Medications were Famotidine and Lipitor. Physical Exam was notable for obese female, increased waist circumference, nontender and non distended abdominal exam without rebound or guarding. CBC,BMP,PT/INR were within normal limits. Liver Function: AST 54 U/L, ALT 78U/L, Alkaline Phosphatase 56 U/L, Total Bilirubin 1.0 mg/dL. Ultrasound revealed hepatic steatosis, and FibroScan showed Fibrosis Score F4 consistent with cirrhosis. She did not have physical exam or lab findings consistent with cirrhosis. Patient was planned for ESG for weight loss and given Fibroscan results, same session EUS-LB was performed. EUS-LB was performed first in left lobe with 19 gauge FNB needle with no complications. ESG was performed successfully without complications. Upper GI series the next morning revealed no extravasation, patient tolerated diet and was discharged home. One month later, patient BMI decreased from 51kg/m2à45kg/m2, 298 to 263 lbs. No complaints of abdominal pain, nausea, vomiting and tolerating diet. Pathology from Liver Biopsy showed NAS Score 4/8 consistent with steatohepatitis, Stage 2-3 fibrosis.

DISCUSSION:
EUS-LB is an effective method for liver biopsy with minimal complications. ESG significantly reduces BMI with low morbidity . With the prevalence of NAFLD and subsequent conversion to NASH and cirrhosis increasing, non-invasive tests are utilized to stage fibrosis in patients with NASH. In cases where there is a discordance between clinical findings and Fibroscan results, liver biopsy can be obtained. This case demonstrates when a liver biopsy is indicated, EUS-LB is a safe and efficient option in a patient undergoing an endoscopy for other reasons. This is also the first reported case of EUS-LB and ESG in the same session. We demonstrate this procedure can be considered simultaneously in patients undergoing ESG to aid in weight loss for fatty liver disease.
2186 An Uncharacteristic Diagnosis of Small Cell, High-Grade Neuroendocrine Carcinoma of the Esophagus
Authors: Kubliun Maddie , Tran Minh , Agrawal Deepak 
Published: October 2019

INTRODUCTION:
Small cell/high-grade neuroendocrine carcinoma of the esophagus is a rare malignancy, of which few cases have been reported in the United States. Here, we report the case of a young patient with small cell/high-grade neuroendocrine carcinoma of the esophagus to demonstrate its aggressive nature and the need for more effective therapy.

CASE DESCRIPTION/METHODS:
A 36-year-old man with recently-diagnosed type 2 diabetes presented with one month of jaundice, dysphagia, postprandial emesis, and 25-pound weight loss. Exam was notable for scleral icterus and jaundice with a benign abdomen. Labs revealed abnormal liver chemistries - AST of 244, ALT of 637, alkaline phosphatase of 309, GGT of 1353, total bilirubin of 10.6, direct bilirubin level 6.5. MRI of the abdomen showed thickening at the GE junction with enlarged adjacent lymph nodes, enhancing liver lesions and peripheral lesions in the pancreas. EGD revealed a mass in the lower third of the esophagus that obstructed the lumen. EUS showed invasion into the muscularis propria and enlarged regional lymph nodes. There was also a lesion in the pancreatic head leading to biliary obstruction. ERCP was performed and a stent was placed in the CBD with subsequent resolution of jaundice and improvement in liver chemistries. The biopsy of the esophageal mass revealed the following immunohistochemistry findings: synaptophysin (+), chromogranin (+), CDX2 (+), Ki67 proliferation index of 100%, p63 (-), and TTF-1 (-). The diagnosis was made of invasive high-grade small cell esophageal neuroendocrine carcinoma. Biopsy of the pancreatic mass revealed benign pancreatic acinar cells and ductal epithelium.

DISCUSSION:
Small cell/high-grade neuroendocrine carcinoma of the esophagus is rare and has a poor prognosis. It is an infrequent type of esophageal cancer and comprises <3% of all esophageal malignancies. It can occur in all age groups but is prominent in men during the fifth decade of life. IHC studies play an important role in the diagnostic process, but their application is limited in locating the primary site of the metastatic neuroendocrine cancer. CDX2 and TTF-1 have been shown to be effective in differentiating intestinal tract NEC from malignancy of the lungs and other locations. Treatment involves the use of chemotherapy that has been shown effective in small cell NEC in the lungs. More studies are needed to understand the biological features of this cancer, its diagnostic approaches, and a therapy regimen that provides better long-term survival rates.
2187 Successful EUS-Guided Gastrojejunostomy in Altered Anatomy After Failed Surgical Management
Authors: Mann Sarabdeep , Ahmed Shifat , Al-Jashaami Layth , Pitea Teodor 
Published: October 2019

INTRODUCTION:
Endoscopic ultrasound (EUS) guided gastrojejunostomy is a recognized technique for relief of benign and malignant gastric outlet obstruction (GOO). This technique creates a fistulous tract between the stomach and the jejunum via placement of a lumen apposing metal stent. It has been shown to be technically and clinically successful in many patients with GOO, however its feasibility in the setting of altered postsurgical anatomy is less clear.

CASE DESCRIPTION/METHODS:
We present a 70-year-old female who underwent a laparoscopic cholecystectomy complicated by bile leak and duodenal perforation requiring a Roux-en-Y gastrojejunostomy. In the following year she developed GOO related to stenosis at the GJ anastomosis. Endoscopic placement of an esophageal covered metal stent across the anastomosis did not provide long term resolution of GOO and was followed by a second surgical revision of her gastrojejunostomy. Unfortunately, she continued to have significant nausea and recurrent vomiting. Repeat EGD and upper GI series showed persistent GOO at the level of the anastomosis. Therefore, a decision was made to attempt EUS guided gastrojejunostomy.
A gastroscope was advanced past the anastomosis and a guide wire was placed into the jejunum. Next, a 20 mm balloon catheter was advanced over the wire to the proximal jejunum using fluoroscopic guidance. An EUS echoendoscope was then inserted sideways to the balloon and used to identify the distended proximal jejunum in close proximity to the gastric wall. The jejunum was punctured under EUS guidance with a 19-gauge needle. A 0.025" guidewire was advanced through the needle under fluoroscopy into the proximal jejunum. A 15 mm × 10 mm AXIOS stent was advanced over the wire, and successfully deployed with the flanges in close approximation to the walls of the proximal jejunum and stomach. (Image 1). Upper GI series showed no evidence of leak and adequate gastric emptying across the gastrojejunal stent. The patient was discharged two days later on a low residue diet. Repeat EGD and upper GI series six weeks later showed no signs of GOO with a patent AXIOS stent (Image 2). At 6 month follow-up the patient continues to have complete resolution of nausea and vomiting.

DISCUSSION:
EUS guided gastrojejunostomy using lumen apposing covered metal stents can be a safe and effective option for management of GOO in patients with altered anatomy. However, there still remains need for long term follow up to determine the durability of such novel endoscopic interventions.
2189 Lavaging the Esophagus of Food Obstruction
Authors: Park Connie , Shenoy Vinayak , Nocerino Angelica , Ivanina Elena 
Published: October 2019

INTRODUCTION:
Esophageal obstructions are usually due to a food bolus or foreign body ingestion in the setting of underlying esophageal disease. They are medical emergencies, requiring endoscopy within 24 hours of presentation, as failure to intervene can lead to perforation, fistula formation, or aspiration. Standard treatment consists of using a fiberoptic endoscope to advance the object into the stomach or retrieving it proximally. We describe the case of an esophageal obstruction from mashed potatoes. Due to its consistency, the obstruction could not be fully cleared with standard techniques and required an off-label use of gastric lavage for removal.

CASE DESCRIPTION/METHODS:
A 94-year-old female presented to our hospital complaining of three weeks of nausea, vomiting, and poor oral intake. Despite primarily consuming mashed potatoes, her symptoms worsened, with emesis of any solid foods or medications. She denied any history of dysphagia, esophageal dysmotility, or food impaction. Vital signs were stable and her abdominal exam was benign with no peritoneal signs. Abdominal computed tomography demonstrated a distal esophageal obstruction with proximal dilation. Upper endoscopy revealed food impaction with thick fibrinous food particles extending the entire length of the esophagus. Proximal retrieval with Roth Net retrievers, biopsy forceps, and tripod forceps was attempted for over two hours with minimal clearance. Given poor visualization and extent of esophageal involvement, the push technique could not be safely performed. Food particles repeatedly clogged the endoscope despite the use of diet ginger ale to break up the food. Hours later, success was finally achieved through gastric irrigation with the Ewald tube.

DISCUSSION:
Esophageal obstruction due to mashed potatoes is rare, and the standard methods of clearance may be ineffective at clearing its fibrinous content. Gastric lavage, routinely used in drug overdose to clear toxic ingestions, consists of inserting a tube (such as an Ewald tube) into the stomach via the mouth with sequential passing of water or saline to remove stomach contents. The same approach was applied to our patient to clear the fibrinous remnants adhering to her esophagus. This case appears to be the first reported use of gastric lavage to clear esophageal obstructions. When available, gastric lavage appears to be an effective method of managing esophageal soft food obstructions and may be considered as a last resort measure when all other methods have failed.
2191 EUS-Directed Transgastric ERCP (EDGE) for Removal of Cystic Duct Coils: A Novel Application of an Emerging Technique
Authors: Kumar Vikas , Parvataneni Swetha , Khara Harshit S. , Obuch Joshua , Deivert Duane , Khan Yakub 
Published: October 2019

INTRODUCTION:
Presence of obesity as well as sudden weight loss, both predispose to gallstone disease. Post roux-en-y gastric bypass (RYGB) anatomy creates additional challenges for endoscopy and surgery. We present a captivating case of post-RYGB complicated gallbladder (GB) surgery, which eventually ends with coiling of cystic duct. The coil formed a nidus for infection and biliary obstruction, and the novel technique of EUS directed trans-gastric ERCP (EDGE) comes to the rescue.

CASE DESCRIPTION/METHODS:
A 27-year-old male with morbid obesity underwent RYGB. Over next 6 months, he lost 130 lbs (35% of total body weight). Three years after RYGB, he presented with acute calculous cholecystitis; requiring laparoscopic-converted to open cholecystectomy due to gangrenous GB and extensive adhesions. Postoperatively, a large cystic duct leak developed, requiring percutaneous transhepatic biliary drainage. Due to persistent leak IR-guided coil embolization of the cystic remnant was successfully done.After three years he presented again with RUQ pain, nausea and fever. CT showed cystic duct coil migration into the CBD with upstream dilation. An EDGE procedure with a 20 mm lumen apposing metal stent was performed with successful biliary sphincterotomy and biliary stones and sludge removal. The migrated coils were removed with a rotating action of the biopsy forceps advanced intraductally which facilitated wrapping of the coils around the forceps, and then removed with a snare.

DISCUSSION:
Obesity pauses high risk for cholelithiasis due to change in fat metabolism, hormonal regulation and GB motility. Significant weight loss further leads to gallstone formation. Our patient presented with acute calculous cholecystitis. Cholecystectomy was complicated by bile leak and led to percutaneous biliary (PTC) drainage. Lap-assisted ERCP could not be performed due to high risk of morbidity in this patient. Instead of PTC and coil placement, EDGE may have been a better option at that point. Patient ended up requiring EDGE due to development of cholangitis associated with biliary obstruction due to migrating cystic duct coils. In this complicated young patient with abdominal adhesions, EGDE was a saving grace, as the alternative may be to live with PTC drain lifelong.
2192 Endoscopic Drainage of a Perirectal Abscess Into the Rectal Lumen With a Lumen-Apposing Metal Stent Avoiding Percutaneous Drainage and the Presence of a Trans-Gluteal Catheter
Authors: Pineda Bonilla Jonh J. 
Published: October 2019

INTRODUCTION:
A 37-year-old woman developed abdominal pain, and diarrhea six weeks after a total hysterectomy with bilateral Salpingo-Oophorectomy was performed for a benign indication. A computer tomography (CT) scan of the abdomen and pelvis with intravenous contrast showed a perirectal abscess, measuring 6.2 × 5.7 × 6.1cm Figure 1. The perirectal abscess was drained transrectally by placement of a cautery enhanced 10 × 10 mm lumen opposing metal (LAM) stent, creating a fistula between the abscess and the rectum.

CASE DESCRIPTION/METHODS:
Using a transrectal approach, the perirectal abscess was imaged by endoscopic ultrasound (EUS). Under doppler ultrasound and fluoroscopic guidance, the abscess was punctured with a 19gauge fine needle aspiration (FNA) needle. A 450cm x 0.025-inch wire was passed through the needle and allowed to coil multiple times in the abscess for stability. The LAM stent was advanced over the wire 4 cm into the abscess and deployed in position Figure 2. There were no complications. Three weeks after the endoscopic placement of the LAM stent, a CT scan showed complete resolution of the perirectal abscess Figure 3. The same week, the stent was removed endoscopically without complications.

DISCUSSION:
This case demonstrates that LAM stents can be safely use for drainage of perirectal abscesses and non-malignant, wall mature perirectal fluid collections. The dumbbell shape design of the stent keeps the fistula tract intact preventing leaks and decreasing the incidence of stent migration and perforations. To safely deploy the distal end of the stent inside the fluid collection, the stent's catheter needs to be advanced 4 cm into the collection before deployment. If this is not accomplished the distal end of the stent may be deployed outside of the fluid collection causing a perforation. If a stable position of the EUS scope is secured there is no need to puncture the fluid collection with a 19-gauge FNA needle, nor to pass the wire into the cavity, because it can be directly accessed with the cautery enhanced tip of the stent's catheter affording a much shorter procedure time.Cases of bleeding have been reported after the collection has been drained and the cavity has collapsed; it is therefore suggested that the optimal time for stent removal is three weeks after stent placement once the fistula tract has been formed and resolution of the collection is confirmed by cross sectional imaging.