bluuebunny/crossref_metadata_2025_split huggingface dataset:
3089 Orifice to Orifice Evaluation, in a Single Exam
Authors: Nakshabendi Rahman , Klair Jagpal S. , Hasan Yazan , Gerke Henning , El Abiad Rami 
Published: October 2019

INTRODUCTION:
We present a case of a middle age Caucasian male with Peutz-Jeghers syndrome who underwent an antegrade double balloon enteroscopy (DBE) for surveillance of a known small bowel polyps. He has a history of right hemicolectomy for a large polyp and subsequent partial small bowel resection for intussusception of a jejunal polyp. He had a DBE a year ago which revealed several small bowel polyps, the larger ones requiring therapeutic intervention. We show a video demonstrating feasibility of complete entero-colonoscopy dictated by necessity.

CASE DESCRIPTION/METHODS:
A 55-year-old Caucasian male with Peutz-Jeghers syndrome presented for his surveillance antegrade DBE. He has history of right hemicolectomy & partial jejunal resection due to intussusception deemed secondary to a large hamartomatous polyp. He has been getting EGD, Colonoscopy and antegrade DBE every 2 years given his history of multiple large hamartomatous polyps. His vital signs, physical examination and lab work were unremarkable.

DISCUSSION:
This patient underwent antegrade DBE with a therapeutic double-balloon enteroscope (Fujinon EN-450 T5) using push and pull maneuver, under general anesthesia and utilizing CO2 for insufflation. A stiffening device (Zutron medical) was used during portions of the procedure to help prevent loop formation. Around the distal jejunum, the stiffening device snapped within the biopsy channel at the boot of the insertion tube of the enteroscope. Given that a significant amount of time has been already invested in the procedure an attempt at reaching the anus was pursued with success. The stiffening device was pushed out of the channel using a biopsy forceps and the procedure was resumed. Multiple polyps (atleast 30) were observed in the small bowel ranging in size from 4-25 mm, some of which were oozing. The oozing polyps and those larger than 10 mm (total 6) were resected. The procedure was completed with no adverse events. The patient's oral cavity was cleaned using hydrogen peroxide swab before he was extubated and sent to recovery. The patient experienced no infection related complication, bleeding, perforation or pancreatitis.

CONCLUSION:
1. It is feasible and safe to perform through and through entero-colonoscopy in specific scenarios. 2. Panendoscopy in one encounter may not always be achievable in patients without a history of bowel resection. 3. Advancing the enteroscopy outside the anus may be considered to clear an obstructed biopsy channel as an option to salvage a long procedure.
Watch the video: http://bit.ly/2XTDKhY
3094 Esophageal Strictures After Ingestion of Picosulfate Powder for Colonoscopy
Authors: Kim Seongmin , Kwon Hyeonwoo , Lee Jun Su , Cho Byungha , Choi Jongwook , Park Seon Mee 
Published: October 2019

INTRODUCTION:
Picosulfate solution is widely used as a small volume bowel cleansing agent considered to be effective and relatively safe.

CASE DESCRIPTION/METHODS:
A 75 - year - old woman came to our hospital with severe neck pain that occurs when she swallows food. A week before our hospital visiting, she had scheduled the EGD and colonoscopy for a health checkup. At the time of EGD, there was white exudates and hemorrhagic spots in the esophagus. But, she had any pain at that time. After 1 week she felt a severe sore throat, visited otolaryngologist, but she was told there was nothing wrong. Despite of medication, she continued to suffer severe pain and she came to our emergency room and received otolaryngologist consultation. However, she was told that she had no particular abnormal findings. She underwent an EGD to examine the cause of the neck pain. The EGD showed multiple superficial ulcers and yellowish exudates throughout the esophagus (Figure 1). We had a biopsy in the esophagus. The result was candidiasis. One week later, she had difficulty in swallowing, and she had another EGD. The esophageal lumen was narrowed at the position of upper incisor (UI) 20 ∼ 30 cm and multiple ulcers were scattered and the endoscope could not pass to the distal side of the esophagus (Figure 2). We investigated her medication history to find out why she had the esophageal strictures. She was being treated for diabetes and atrial fibrillation 20 years ago, and we found she had taken picosulfate powder for colonoscopy a week ago. She mistakenly took the picosulfate powder first, drank the water later. She felt a little uncomfortable with the epigastric area, but she thought it was nothing. During her hospital stay, she was treated conservatively, including fasting, antibiotics, and parenteral nutritional support. After her symptoms improved, she was discharged. About a month later, she came to the outpatient clinic because of dysphagia for solid food. EGD showed esophageal stricture at UI 25 cm and passed through the site using a ultrathin scope. The narrowed area of the UI 30 cm was not able to pass through the endoscope (Figure 3). Using a guide wire, a 10 cm full covered metal stent was inserted through the scope.

DISCUSSION:
We reported a case of esophageal ulcer and stricture caused by a picosulfate power that the patient took accidentally. When picosulfate powder is used as a bowel cleansing agent, patient should be educated to take after dissolving it more than 200 mL of water to avoid esophageal injury.
3095 Non-Celiac Gluten Sensitivity (NCGS) Presenting as Laryngopharyngeal Reflux (LPR)
Authors: Son Joseph , Havranova Jana , Jaworek Aaron 
Published: October 2019

INTRODUCTION:
Laryngopharyngeal reflux (LPR) is defined as retrograde passage of stomach contents through the esophagus into the larynx and pharynx. Celiac adhering disease is known to cause more severe reflux, often refractory to anti-secretory medications like proton pump inhibitors (PPI). In those cases, the patient will frequently experience symptom relief by adherence to a gluten free diet (GFD). However, little is known about non-celiac gluten sensitivity (NCGS), and the only commercially available test, Antigliadin (AGA) IgG, is positive in about 60% of patients. We present a case of LPR refractory to anti-secretory medication, low acid diet, and reflux surgery that resolved rapidly on a gluten free diet after diagnosing NCGS.

CASE DESCRIPTION/METHODS:
A 59 years old woman with PMH of gastric bypass surgery (roux-en-Y), GERD, hypothyroidism, MDD, and migraine presented with symptoms of hoarseness, mucous throat clearing, cough, sour taste, and nocturnal choking/laryngospasm events. Flexible fiberoptic laryngoscopy supported the diagnosis of LPR with classic findings of laryngeal edema, erythema, and inflammatory mucus. Treatment with omeprazole 40 mg BID, ranitidine 300 mg QHS, and aluminum hydroxide/magnesium carbonate failed to resolve her symptoms. Persistent severe acid reflux and strong symptom correlation were confirmed with dual sensor pH impedance while esophageal manometry confirmed hypotonic lower esophageal sphincter pressure. She underwent paraesophageal hernia repair and Dor fundoplication resulting in temporary resolution of symptoms that returned one month postoperatively. Although she was unaware of any gluten intolerance, she was tested for gluten sensitivity. Tissue Transglutaminase (TTG) IgA/IgG and Deamidated Gliadin Peptide (DGP) IgA/IgG were normal, but AGA IgG was elevated (111), suggestive of NCGS. She was instructed to follow a GFD, and within one week, all reflux symptoms had resolved, along with headaches, joint pain, and “foggy” mind.

DISCUSSION:
The patient had classic signs and symptoms of LPR, responsive to GFD, after NCGS was determined by elevated AGA IgG. NCGS remains the least understood form of gluten sensitivity, unlike its counterparts celiac disease and wheat allergy. By exploring the potential connections between LPR and gluten sensitivity, it becomes apparent that some of these patients have gluten sensitivity as the root cause of their reflux symptoms and laryngeal inflammation. More research is needed to better understand the influential diagnosis of NCGS.
3098 Small Plastic Objects Can Cause Foreign Body Impaction in Normal Adult Esophagus
Authors: Paul Navin 
Published: October 2019

INTRODUCTION:
Foreign body impaction in the esophagus results from an inability of a swallowed object to pass through the esophagus to the stomach. In the United States, food, especially boneless meat, is the most commonly impacted foreign body. When impaction of a foreign body occurs in an adult esophagus, it usually occurs in the presence of underlying structural abnormalities (such as a web or stricture), functional abnormalities resulting from abnormal esophageal peristalsis, or when the swallowed object is too large to navigate the anatomic constrictions of the normal esophagus. This report describes two patients who had retained plastic foreign bodies in the esophagus in the presence of a normal esophageal anatomy.

CASE DESCRIPTION/METHODS:
Patient 1: A 39 year old man came to emergency room after accidentally swallowing a 2 cm plastic ring. He was able to swallow fluids and oral secretions, but felt a foreign body sensation in his upper chest. He denied any prior dysphagia. On endoscopy, a white plastic ring was seen in the mid-esophagus with no associated esophageal injury. Esophagus was normal with shiny mucosa. With insufflation and gentle prodding with the endoscope, the plastic ring easily passed into the stomach where it was captured using an endoscopic net and retrieved. The patient was discharged home after the procedure. Patient 2: A 53 year old woman presented to the emergency room with history of foreign body sensation and odynophagia localized to mid-chest after drinking an open cup of water. She was able to swallow water and oral secretions, but felt a sharp pain in the mid-chest every time she did so. Although she had seen a foreign body, she was convinced that she had foreign body stuck in her esophagus. Endoscopy showed a thin square piece of plastic measuring about 1 cm in size retained in a normal appearing esophagus with no obvious esophageal injury. It was retrieved using an endoscopic net. She was discharged home after the procedure.

DISCUSSION:
This report demonstrates that foreign bodies made of plastic can be retained in the adult esophagus in the absence of traditional risk factors. They can also present with atypical clinical features. The composition of plastic may make it more adherent to the esophageal mucosa thus preventing easy transit through the esophagus, even in the absence of restrictions in the esophagus. This report demonstrates the importance of endoscopic evaluation when a foreign body is suspected, even in the absence of a traditional presentation.
3103 A Case of Multiple Peptic Strictures Requiring Multistage Dilatation: A Challenging Esophagus
Authors: Nawaz Waqas , Fernandes Nikita , Hertan Hilary 
Published: October 2019

INTRODUCTION:
Peptic strictures are benign esophageal strictures that result from chronic gastroesophageal reflux disease (GERD). Endoscopic dilatation is the treatment of choice. However, some strictures are complicated and difficult to manage. We present a case of an elderly male with two benign esophageal strictures, which were dilated in multiple sessions.

CASE DESCRIPTION/METHODS:
A 66-year-old male with a history of GERD, heavy smoking, excessive use of NSAIDS and alcohol was admitted for chronic dysphagia to solids for the last two years worsening over the last few months without significant weight loss. Physical exam and initial laboratory data were unremarkable. Upper endoscopy showed a benign appearing stricture at 18 cm from the incisors which could not be traversed with a regular or a pediatric scope. Barium esophagogram showed two areas of stricture in the proximal and the distal esophagus. The proximal stricture was dilated using a balloon dilator through the scope in multiple sessions. Finally, a10 mm dilatation was achieved where the pediatric scope traversed the stricture to examine the distal esophagus, which revealed esophageal diverticulosis. It showed a complex stricture at 36 cm from the incisors which was traversed. Biopsies showed intra-epithelial lymphocytes consistent with GERD without any eosinophil or atypical cells. Fluoroscopy guided dilation was done using Savary dilators up to a 14 mm diameter in three sessions with clinical improvement. Cessation of smoking, heavy alcohol and NSAIDS use was advised, and a proton pump inhibitor was started.

DISCUSSION:
Stricture formation occurs in 7–23% of patients with reflux esophagitis and GERD. Long term acid exposure results in chronic esophagitis with subsequent fibrosis of the muscularis propria leading to a fibrotic narrowing of the esophagus with formation of diverticula. Risk factors include male gender, advanced age, GERD, heavy alcohol use and NSAIDS. Work up includes upper endoscopy and barium esophagogram. Differentials include eosinophilic esophagitis and lye strictures. Biopsies are mandatory to rule out malignancy. Treatment involves acid suppression and dilation using wire guided polyvinyl bougie dilators under fluoroscopic or endoscopic guidance and balloon dilators which are passed through the endoscope. Perforation and bleeding may occur in 0.5 % cases. Our case was challenging as malignancy at the distal stricture could not be ruled out until the proximal stricture was dilated enough for the endoscope to traverse.
3104 Esophageal Hematoma: A Colossal Obstacle
Authors: Master Vidisha , Mehta Amit , Niec Rachel , Crawford Carl V. , Wan David 
Published: October 2019

INTRODUCTION:
Esophageal hematomas are rare but well described phenomena that can present as retrosternal chest pain, hematemesis, and dysphagia. They are seen in association with anticoagulation therapy, mechanical trauma, and increased intraesophageal pressure as caused by excessive retching and vomiting. We describe a case of esophageal hematoma following catheter ablation for treatment of atrial fibrillation.

CASE DESCRIPTION/METHODS:
A 73 year old female with chronic obstructive pulmonary disease, nephrectomy, rheumatic heart disease status post mechanical mitral valve on warfarin, refractory atrial fibrillation was admitted for hematemesis after elective atrial fibrillation ablation. The patient underwent TEE during which an esophageal probe was required for repositioning of the esophagus. No blood was seen when the probe was removed, but at the end of the procedure the patient had hematemesis. INR at presentation was 3.7. The patient was emergently intubated and an EGD revealed a large clot occluding the mid-esophagus, denuded mucosa with oozing from multiple sites, and a large clot in the fundus (Figure 1). A chest CTA showed circumferential esophageal thickening and distention with non-enhancing blood products extending from above the thoracic inlet to the GE junction, with clot also outlined by oral contrast within the gastric lumen. No definite communication between the esophagus and atrial pulmonary veins was identified. A repeat endoscopy the next day again showed the large esophageal hematoma (Figure 2) and was aborted to avoid additional esophageal trauma. A week later, CTA chest showed persistent esophageal intramural hematoma with no evidence of aortoenteric fistula. Cardiothoracic surgery was consulted and placed a percutaneous gastrostomy tube. The patient was recovering well, but shortly upon extubation, the patient died of cardiorespiratory arrest.

DISCUSSION:
Esophageal hematomas typically develop in middle-aged women and present as a triad of retrosternal chest pain, dysphagia and hematemesis. The mechanism producing the hematoma may determine the site. For example, a hematoma from vomiting would be at the esophagogastric junction, whereas from a caustic substance might be at points of narrowing. It can be visualised on endoscopy or as a filling defect on barium esophagogram. Computed tomographic images reveal a mass confined to the esophageal lumen that does not enhance with injection of contrast medium. Conservative and supportive care remains the main therapeutic modality.
3105 Zenker's Diverticulum: Unusual Cause of Acute Oesophageal Impaction
Authors: Ali Hammad , Rahim Usman , Ehrinpreis Murray N. 
Published: October 2019

INTRODUCTION:
Dysphagia amongst the elderly results from increasing dysfunction of the upper esophageal sphincter (UES), which is vulnerable to effects of aging. Prevalence of dysphagia in geriatric population, especially above 80 is higher than overall prevalence in the general population. Zenker's diverticulum (ZD) is the hallmark pathology for UES dysfunction. These false diverticula are herniation of mucosa and submucosa through the Killian's Triangle. Albeit progressive dysphagia is the most common presentation, symptoms can range from globus sensation to obstruction. ZD may rarely present as complete esophageal obstruction.

CASE DESCRIPTION/METHODS:
An 89 years old female with hypertension, osteoarthritis and polycythemia vera presented with complaint of “having a pill stuck in my throat.” Unable to tolerate her breakfast and spitting up sputum. Similar symptoms in the past for which she changed her diet to soft bread. Initially, it worked however dysphagia gradually worsened to the extent of having to butter her pills to ease swallowing. Denies GERD. Vital signs within normal limits, physical exam revealed enlarged multinodular goiter with retropharyngeal extension however negative Pemberton's sign. Boyce sign was positive on sipping some water. Euthyroid and no other abnormalities. Urgent upper endoscopy was recommended however patient refused but agreed the next day. Endoscopy was remarkable for pill lodged in upper esophagus, upper esophageal ring and impacted food in ZD compressing esophagus. The ring was split using the endoscope and pill pushed down which was then propelled by peristalsis to the stomach. Content of ZD was retrieved with Roth net. Remaining endoscopy exam was unremarkable. ENT evaluation was recommended for ZD and goiter however patient declined intervention.

DISCUSSION:
ZD often presents as solid food and pill dysphagia, rarely as acute esophageal obstruction as seen in this case. A number of factors in addition to external esophageal compression by the enlarging ZD likely contributed to her presentation, including pressure from enlarged thyroid. ZD compounds the pharyngeal weakness that leads to its development, trapping the patient in a vicious cycle of worsening dysphagia that eventually results in obstruction. Furthermore, an association between esophageal webs and ZD has been demonstrated. Combination of these factors resulted in the complete obstruction in our patient. Dysphagia in old age, always have ZD in mind.
3106 Cirrhosis and Barrett's? WATS-3D as a Screening Tool
Authors: Srinivasan Sachin , Agha Yasmine Hussein , Hyder Jeffrey , Wuthnow Chelsea , Kilgore William , Tofteland Nathan , Salyers William 
Published: October 2019

INTRODUCTION:
Barrett's esophagus (BE) is a pre-malignant condition in patients with long-standing GERD. The gold standard for diagnosing BE is taking 4-quadrant esophageal biopsies during endoscopy followed by demonstration of intestinal metaplasia on histopathology. However, in patients with cirrhosis, taking biopsies is rendered difficult due to an increased risk of bleeding due to esophageal varices and coagulopathy. This case series reports three patients with cirrhosis that were successfully diagnosed with BE using WATS3D (Wide angle trans-epithelial sampling with computer assisted 3 dimensional tissue analysis).

CASE DESCRIPTION/METHODS:
Case 1: 66 year-old female with a history of cirrhosis secondary to autoimmune hepatitis, esophageal varices, GERD and previously diagnosed BE that had liver and kidney transplants 3 years prior to presentation. Case 2: 63 year-old male with a history of BE, Laennec's cirrhosis, esophageal varices and portal hypertensive gastropathy. Case 3: 62 year-old male with a history of cirrhosis due to untreated hepatitis C and alcohol abuse, known carrier for HFE gene, GERD and BE. Case 1 and 2 had WATS3D brushings and mucosal biopsies, while Case 3 had WATS3D brushings alone due to concerns of bleeding. The findings are described in Table 1. There was agreement between the WATS3D analysis and biopsy results in the 2 patients. The patient with WATS3D brushings alone had evidence of goblet cell metaplasia. There were no immediate or post-procedural complications (bleeding, infections) in any of the patients.

DISCUSSION:
Review of literature suggests that the prevalence of GERD and neoplastic progression in patients with cirrhosis is higher compared to patients without liver disease. However, weighing the benefits and risks of taking biopsies during EGD, many cases of BE go undetected when physicians refrain from taking biopsies and rely solely on endoscopic findings. WATS3D uses a minimally invasive brush biopsy that resects wide area tissue samples, allowing analysis of the full trans-epithelial thickness of the esophagus. It is less invasive than forceps biopsy, has a higher sampling yield, and would be safer in patients at high risk of bleeding complications in patients similar to those presented in this case report.
3107 A Case of Refractory Hyponatremia Treated by Anti-fungal Therapy
Authors: Mukherjee Samiran , Harne Prateek , Sharma Anuj , Singh Avneet , Manocha Divey 
Published: October 2019

INTRODUCTION:
Hyponatremia is a commonly encountered condition in the ICU setting. Refractory hyponatremia due to esophageal/duodenal candidiasis is an unreported entity and is amenable to treatment with antifungal therapy.

CASE DESCRIPTION/METHODS:
We present a 74 year old lady who presented with shortness of breath and bilateral pleural effusions secondary to congestive heart failure with low sodium levels. Her co-morbid history included esophageal squamous cell carcinoma status-post esophagectomy with a duodenal conduit. The hyponatremia, initially thought to have been due to SIADH was non-responsive to fluid restriction and administration of salt tablets. Given her altered gut anatomy, it was later revealed to be due to malabsorption in either the duodenal conduit as a result of candidal duodenitis or due to an unconfirmed concomitant jejunal candidiasis. It had resolved after the candidiasis was treated with fluconazole therapy for a duration of 2 weeks.

DISCUSSION:
The occurrence of esophageal candidiasis in an immunocompetent individual is rare, more so is the occurence of pseudo-esophageal (duodenal) candidiasis. This case serves as an important teaching tool to understand the pathophysiology of hyponatremia in the setting of altered gut anatomy allowing us deeper insights into electrolyte balance.