bluuebunny/crossref_metadata_2025_split huggingface dataset:
2164 Percutaneous Transhepatic Single-Operator Cholangioscopy With Electrohydraulic Lithotripsy in the Management of Intrahepatic Stones in a Post-Orthotopic Liver Transplant Patient With Ischemic Cholangiopathy
Authors: Stadmeyer Peter , Dalvie Prasad , Hubers Jeffrey , Gopal Deepak 
Published: October 2019

INTRODUCTION:
Advancements in endoscopic retrograde cholangiopancreatography (ERCP) have revolutionized the management of biliary stones. However, endoscopic management of intrahepatic stones continues to be challenging. We discuss a patient with intrahepatic stones who was treated with percutaneous transhepatic cholangioscopy with electrohydraulic lithotripsy (EHL).

CASE DESCRIPTION/METHODS:
A 68-year-old man with alcoholic cirrhosis underwent orthotopic liver transplant from a deceased after cardiac death donor. His post-transplant course was complicated by ischemic cholangiopathy, biloma development and recurrent episodes of cholangitis. He underwent placement of an external biliary drain for management of his biloma. An MRCP demonstrated persistent biloma as well as mural irregularities within the intrahepatic ducts concerning for intrahepatic stones. Due to recurrent cholangitis, a combined IR (interventional radiology)-biliary endoscopic procedure was undertaken. IR performed a percutaneous cholangiogram (PTC) which demonstrated multiple filling defects in the left hepatic ducts consistent with stones. A 5 French Fogarty balloon was advanced and inflated with multiple sweeps in an attempt to extract the filling defects into the common bile duct. Antegrade cholangioscopy was then performed with single-operator cholangioscope (SpyGlass 2™) passed through a 14 French PTC sheath. Using the cholangioscope we were able to visualize impacted stones within the left intrahepatic system and treat them utilizing EHL with a catheter setting of 40-50 Watts for stone fragmentation and suction. The single-operator cholangioscope was then directed at the common bile duct and two large retained stones were treated with EHL. Subsequently, a traditional ERCP was performed which noted filling defects within the common bile duct. Balloon sphincteroplasty was performed and using an 8.5-11.5 mm balloon catheter, CBD exploration and balloon sweeps were performed with extraction of 2 large stones and sludge. Occlusion cholangiogram at the completion of the procedure revealed no further stones and patent anastomosis. To allow adequate biliary drainage, a retrievable 10 mm × 60 mm SEMS covered metal biliary stent and a new 14 French external biliary drain was placed. The biliary stent was removed 3 months later with ERCP demonstrating no recurrent stones.

DISCUSSION:
Complex intrahepatic lithiasis may be successfully managed with a multi-disciplinary collaborative approach between Interventional Radiology and biliary endoscopists.
2167 Endoscopic Closure of a Duodeno-Pleural Fistula Secondary to Transarterial Chemoembolization
Authors: Natov Peter S. , Kesar Sukeerti , Yacavone Robert F. 
Published: October 2019

INTRODUCTION:
Transarterial chemoembolization (TACE) is an increasingly performed treatment for advanced stage hepatocellular carcinoma (HCC) not amenable to surgical intervention. Though effective, it is not without risk. Notable complications include post-embolization syndrome, decompensation of cirrhosis, acute cholecystitis, and acute pancreatitis, and rarely hepatic artery injury, liver abscess, duodenal perforation, and bile duct injury. Fistula formation appears to be among the rarest of complications. We describe the presentation of a duodeno-pleural fistula as a complication of TACE and its endoscopic closure with an over-the-scope clip (OTSC).

CASE DESCRIPTION/METHODS:
A 49-year-old woman with a history of chronic hepatitis B cirrhosis and HCC presented to the emergency room with right-sided chest pain. She was diagnosed with HCC 16 years ago in China and underwent partial hepatectomy and chemotherapy. Two years prior to current presentation, MRI demonstrated a 2.0 × 2.7 × 3.3 cm liver lesion consistent with recurrent HCC. TACE was performed. She subsequently reported abdominal pain. Endoscopy discovered a duodenal ulcer, and imaging noted a developing phlegmon and free air. Management with bowel rest and parenteral nutrition led to clinical improvement without the need for surgery. On this presentation, she described new onset pleuritic chest pain and dyspnea. Imaging revealed a large loculated right pleural effusion with gas foci and visible extraluminal enteric contrast surrounding the duodenal bulb, suggestive of an empyema secondary to a duodeno-pleural fistula (Figure 1). Pleural fluid analysis showed a pH < 6.8, high amylase and lipase levels, and cultures of multiple enteric organisms. Fistula closure was attempted endoscopically. A 4 mm opening was found in the duodenal bulb (Figure 2). The mucosa was denuded with argon beam plasma coagulation and an 11/6t OTSC successfully closed the defect (Figure 3a,b). Extravasated contrast was not seen on imaging two days later.

DISCUSSION:
Endoscopic interventions for enteric fistula closure include suturing, stents, and clips. The OTSC is increasingly recognized as a minimally invasive technique for fistula closure, with strong immediate technical success rates and variable long-term clinical success depending on location. To our knowledge, we demonstrated the first endoscopic closure of a duodeno-pleural fistula. This case supports the role of endoscopic closure with OTSC for enteric fistulae in the non-surgical candidate.
2175 Endoscopic Salvage Repair: Complicated Gastric Sleeve Leak
Authors: Fleming Harrison , Brazeau Michael , Cho Ryan , Magulick John 
Published: October 2019

INTRODUCTION:
Gastric leaks following laparoscopic sleeve gastrectomy (LSG) are a feared complication, occurring in 2.4 % of cases in the proximal portion ( >90%). LSG is more prone to a leak due to a long staple line and high intraluminal pressure, sealed between an intact pylorus and lower esophageal sphincter and less likely to close spontaneously. There are no standardized guidelines for management of this or other forms of anastomotic leaks. We present a case that failed to respond to initial attempt to close with a luminal stenting, which led to multiple techniques to include endoscopic vacuum therapy (EVT), pneumatic dilation of the sleeve, and pylori Botox injection that ultimately achieved success.

CASE DESCRIPTION/METHODS:
51 year old female with a recent history of laparoscopic sleeve gastrectomy complicated by a proximal leak detected 4 weeks post op. She initially underwent endoscopic closure with an Ovesco placement over the defect of the sleeve leak and stent placement across the sleeve. UGI immediately following the procedure revealed no leak. Subsequent imaging two weeks following the procedure revealed a leak, requiring the stent removal. The endoscopic exam revealed a large proximal sleeve defect leading to a large purulent cavity (3 × 4 cm) with multiple sinus openings. She underwent endoscopic vacuum therapy (14 sessions) every 3-4 days, leading to the complete sealing of the cavity and reduction of the cavity. There was a 1 × 1 cm persistent sealed cavity with diffuse granulation tissue, requiring a placement of a double pigtail stent. After functional stenosis was noted under fluoroscopy, not allowing contrast to freely flow downstream, Botox injection of the pylorus and pneumatic dilation of the sleeve (to 30 mm, 3 sessions) were performed, to relieve the pressure gradient. UGI series confirmed the completely sealed nature of the cavity and smooth contrast flow distally to the small intestine. Pigtail stent was left indefinitely to allow natural healing.

DISCUSSION:
Multiple endoscopic techniques have been implemented to close LSG leaks. The new paradigm has focused on optimizing pressure gradients to allow internal drainage with closure of the cavity by secondary intention. Our case described an initial failed closure that ultimately achieved success with a variety of techniques to include internal drain placement and Botox and dilation. This subject would benefit from further study to determine optimal initial or stepwise approach.
2178 What You See Is Not What You Get: EUS Underestimation of Gastric Cardia Mass Size and Shape
Authors: Bill Katherine , Chaar Abdelkader , Barawi Mohammed 
Published: October 2019

INTRODUCTION:
A 67-year-old-male with history of dysphagia was found to have a subepithelial mass in the gastric cardia. It was located anterolaterally along the greater curvature and had normal overlying mucosa. Endoscopic ultrasound demonstrated a 17 mm hypoechoic homogenous lesion arising from the muscularis propria without malignant features (Figure 1). It was most consistent with a leiomyoma. After discussion of the findings and management options, our patient elected to proceed with endoscopic resection.

CASE DESCRIPTION/METHODS:
A single-channel endoscope identified the lesion on retroflexion. After submucosal injection of 0.9% normal saline, methylene blue, and epinephrine, a transverse incision was made in the midsection of the bulging mass, exposing the submucosa. Repeated injections lifted the submucosa for dissection using a T-type hybrid knife. An IT-2 knife (Olympus®) was used to cut the submucosa in a circumferential fashion around the tumor. It was bilobar in appearance (Figure 2) and significantly larger than seen on EUS. All bleeding vessels were cauterized, and a large snare was used to perform en bloc resection of the tumor. We used a transverse midline incision to facilitate resection while minimizing disruption of the overlying mucosa. No mucosa was excised, and the incision was easily approximated for closure using multiple endoclips. The tumor was pale in appearance with an intact capsule. It measured 25 mm at its greatest diameter, which was 8 mm larger than EUS measurement. Histologic examination revealed bland spindle cell proliferation (Figure 3). Immunohistochemical staining was positive for actin and desmin and negative for CD117 and CD34, features consistent with leiomyoma.

DISCUSSION:
Endoscopic surgery is rapidly advancing, providing safe and feasible alternatives to more invasive therapies. We describe successful endoscopic full-thickness resection (EFTR) of a gastric cardia mass whose size and shape were significantly underestimated on pre-operative EUS. We have encountered this in prior cases, most notably lesions originating in the third and fourth gastric layers. Resection of our patient's gastric cardia tumor made this discrepancy particularly challenging, and it is a pitfall of EUS that even the most experienced endosonographers must be cognizant of.
2181 Gallbladder Irrigation via Cholecystostomy Tube as a Novel Technique for Improving EUS-Guidance During Placement of Lumen-Apposing Metal Stent (LAMS) for Cholecystoduodenostomy
Authors: Cummings Donelle , Kwak Nathan , Joseph-Talreja Mairin , Grossman Evan B. , Cheung Derrick 
Published: October 2019

INTRODUCTION:
Cholecystectomy is the preferred treatment of acute cholecystitis, but it may be relatively contraindicated in patients with medical comorbidities or advanced age. Non-surgical approaches include percutaneous transhepatic cholecystostomy tube and endosonographic stent placement. Adequate endosonographic imaging of the gallbladder is essential for correct stent deployment.

CASE DESCRIPTION/METHODS:
A 55-year-old male was admitted for endoscopic cholecystoduodenostomy for palliation of chronic cholecystitis. He had prior admissions for cholecystitis and choledocholithiasis with cholangitis with prior ERCPs requiring sphincterotomy, sphincteroplasty, stone removal and common bile duct stent placement. He was a poor candidate for cholecystectomy due to multiple medical comorbidities and chronic anticoagulation and was referred for endoscopic therapy. The patient was brought to the endoscopy suite and placed under general anesthesia. The Olympus linear echoendoscope was passed to the second portion of the duodenum. The gallbladder was collapsed due to prior patent sphincterotomy and sphincteroplasty. With IR assistance, the gallbladder was irrigated with normal saline boluses of to a volume of 600 mL. Due to the patent sphincterotomy, the gallbladder would collapse requiring additional irrigation. Maximal size of the gallbladder 30 mm in the long axis and 20 mm in the short axis. The duodenal wall and the gallbladder were punctured under endosonographic guidance using the hot AXIOS electrocautery-enhanced delivery system. A stoma was created and a 15 × 10 mm AXIOS stent was placed with flanges in close approximation to the gallbladder and duodenal wall through the cholecystoduodenostomy. The echoendoscope was then withdrawn. Next, a solution of normal saline and methylene blue was injected through the percutaneous cholecystostomy tube and this solution was seen to flow from the duodenal portion of the AXIOS stent on endoscopic views, confirming adequate location of the AXIOS stent in the gallbladder and duodenum.

DISCUSSION:
The patient did well in the immediate post-procedural period. Six days post-procedure, he was noted to have melena in the setting of supratherapeutic INR and aPTT. Repeat upper endoscopy showed no evidence of bleeding. The AXIOS stent appeared normal on endoscopic views. Due to the difficulty of stent placement and palliative intent, we left the AXIOS stent in situ. The patient is currently asymptomatic and was referred to IR for removal of percutaneous cholecystostomy tube.
2193 Role of Endoscopy in Bouveret Syndrome
Authors: Saleem Sheikh A. , Arif Muhammad Osman 
Published: October 2019

INTRODUCTION:
Biliodigestive fistula is a rare complication of cholelithiasis which can lead to gallstone ileus. The gallstone after passing into GI tract is eliminated in 85 % of the cases through the feces or vomitus. However in 15 % of the cases it gets entrapped in the GI tract most commonly in the terminal ileum. We describe a case of an elderly patient who presented with Bouveret syndrome secondary to impaction of the biliary calculus in the first part of duodenum.

CASE DESCRIPTION/METHODS:
A 91 yo M presented to the hospital with one week history of nausea, vomiting and abdominal pain. He was noted to have right upper quadrant abdominal tenderness. Liver function tests were unremarkable. CT abdomen with oral contrast showed findings concerning for gastric outlet obstruction secondary to large lamellated gallstone along with a choledochoduodenal fistula. An upper GI endoscopy was done which showed a large immobile gallstone obstructing the first part of duodenum. An attempt to remove the stone endoscopically by various techniques including mechanical lithotripsy and net extraction was unsuccessful. A 7 cm gallstone partially contained in the gallbladder and extending to the duodenum was then successfully removed by open partial cholecystectomy with duodenal extraction followed by choledochoduodenal fistula repair. Patient recovered well without any complications after the surgery.

DISCUSSION:
Gallstone impaction in the duodenum and pylorus is extremely rare and can lead to gastric outlet obstruction, a condition known as Bouveret syndrome. Bouveret syndrome needs to be managed in a timely fashion. Clinically patients with this condition present with nausea, vomiting and abdominal pain. History of recent bouts of jaundice and biliary colic is seen in up to 70% of the patients. Rarely patients can present with hematemesis secondary to duodenal or celiac artery erosion. CT abdomen with contrast is the imaging of choice. Medium sized mobile stone in the duodenum can be successfully managed endoscopically by lithotripsy or net extraction. However when there is an immobile large calculus, endoscopy often fails and surgical extraction of the stone needs to be done to relieve the obstruction. Nevertheless considering the higher mortality associated with surgery, endoscopic removal of the calculus should be attempted first.
2203 Rare Presentation of a Mast Cell Neoplasm as Liver Fibrosis
Authors: Hayat Maham , Corredine Thomas J. , Hassan Ayesha , Kanagala Rajesh 
Published: October 2019

INTRODUCTION:
Primary myelofibrosis (PMF) is a chronic myeloproliferative disorder characterized by bone marrow fibrosis and extramedullary hematopoiesis mainly involving the liver and spleen. Clinical manifestations of the disease include severe anemia, marked hepatosplenomegaly, constitutional symptoms, cachexia, bone pain, pruritus, thrombosis, and bleeding. Super imposed mast cell neoplasm, in a patient with myelofibrosis is rare. Ascites and liver enzyme derangement as the only presenting symptom of these hematological malignancies, is seldom seen.

CASE DESCRIPTION/METHODS:
54-year-old female, with what was originally thought to be newly diagnosed, decompensated cirrhosis, who was admitted to the hospital with worsening dyspnea and abdominal pain. The patient was suspected to be septic, and admitted to the MICU. Biochemical work up revealed a total bilirubin of 6.5, AST 65, ALT 32, INR 1.3, WBC 28k and platelet count of 12,000. However, during her hospital stay she continued to have worsening of jaundice and liver enzyme derangement, thus the hepatology service was consulted. The patient’s labs were consistent with alcoholic liver disease, but the patient vehemently denied heavy alcohol use. Given the severe thrombocytopenia, out of proportion to usual levels seen in cirrhosis, the hematology/oncology service was consulted. Trans-jugular liver biopsy showed extramedullary hematopoiesis and myelofibrotic changes with superimposed mast cell neoplasm. Subsequently, bone marrow biopsy also revealed erythroid hyperplasia with marked dyserythropoiesis, consistent with myelodysplastic syndrome, in addition to extensive bone marrow involvement by malignant mast cell neoplasm.

DISCUSSION:
Resultant hepatosplenomegaly from PMF in patients may lead to non-cirrhotic portal hypertension, which can lead to variceal bleeding or ascites. These symptoms prior to systemic manifestations of a myeloproliferative neoplasm, are rare. Acute liver failure, as the initial presentation of PMF and mast cell neoplasm is not commonly reported in medical literature. The overall prognosis is generally poor with liver involvement an indicator of an advanced stage of the disease.
2205 Bupivacaine-Induced Liver Injury: A Diagnostic Dilemma
Authors: Syed Tausif A. , Patel Sameer , Alweis Richard 
Published: October 2019

INTRODUCTION:
Bupivacaine is local anesthetic (1). Very few cases of bupivacaine induced liver injury have been noted in the literature; we report a case of this very rare side effect (2).

CASE DESCRIPTION/METHODS:
A 69-year-old male patient underwent a right inguinal herniorrhaphy. One week after the surgery, patient began to have nausea, vomiting, fever, and dark brown urine. Stools were normal and there was no pruritis. There was no previous history of jaundice, chronic liver disease or malignancy. New medication use, alcohol, illicit drug use, risky sexual behavior was negative. On examination, vitals were all within normal limits. Icterus was present but otherwise his skin was only remarkable for the left lower quadrant scar, which was healing well without surrounding erythema or purulent discharge. Liver function tests were notable for a total bilirubin of 17.4 mg/dL, direct bilirubin was 10.8 mg /dL,. AST was 355 U/L, ALT was 570 U/L, alkaline phosphatase was 944 U/L, LDH was 315 U/L. Viral, autoimmune and structural causes of acute hepatitis were excluded. Given the negative evaluation, a retrospective review of medications received during and after surgery was performed, and the patient was found to have received bupivacaine via PCA post-operatively. As all the other options were excluded, the patient was diagnosed with liver injury from bupivacaine. The patient was managed conservatively and recovered fully in about four weeks.

DISCUSSION:
Bupivacaine is a local anesthetic which can be given through elastomer pumps for pain control (1). There are case reports in the literature that suggested bupivacaine can cause liver injury when given for more than one week (2,3). DILI is a diagnosis of exclusion (2,4). The common causes of liver injury such as drugs, alcohol, viruses, autoimmune diseases and biliary tract abnormalities need to be excluded (4). The diagnosis can be established with the help of Naranjo criteria (5) (Table 1). Most of these liver injuries respond to conservative management. There have been no reports of any acute or chronic liver failure in such cases. If the patient is at high risk of liver injury then they should receive local anesthetic agent other than bupivacaine (3).
2206 Nodular Regenerative Hyperplasia in a Patient With Sickle Cell Disease
Authors: Bedi Simranjit , Tosounian Shannon L. , Miick Ronald , Au Jennifer 
Published: October 2019

INTRODUCTION:
Nodular regenerative hyperplasia (NRH) is a rare liver condition caused by transformation of hepatic parenchyma into regenerative nodules. Despite the association between NRH and certain hematologic disorders, specifically myeloproliferative diseases, there are very few reports of NRH associated with sickle cell disease (SCD). We present a patient with SCD with liver biopsy confirmation of NRH and sickle cell hepatopathy.

CASE DESCRIPTION/METHODS:
A 45-year-old male with history of hypertension and sickle cell anemia (hemoglobin SS phenotype) was initially referred to hepatology due to concerns for cirrhosis on CT scan. He had been admitted for significant fatigue and a CT thorax was obtained due to opacity on chest X-ray. This study showed findings concerning for cirrhosis with high density in the liver suggesting hemosiderosis; this was new compared to imaging five years prior. Upon initial evaluation in clinic, he was asymptomatic and fatigue had resolved since receiving blood transfusion during his hospitalization. He had normal vital signs and benign physical exam. Pertinent laboratory results included: AST 39 IU/L, ALT 19 IU/L, Total Bilirubin 2.35 mg/dL (Direct Bilirubin 0.7 mg/dL), Alkaline Phosphatase 81 IU/L, INR 1.0, Hemoglobin 8.3 gm/dL. His ferritin was 1021 ng/mL, a hepatitis panel was negative, and anti-mitochondrial antibody was elevated at 24.5 units. A liver ultrasound with dopplers demonstrated increased echogenicity, mildly coarse echotexture, with an irregular contour consistent with cirrhosis. To delineate the cause of his liver disease, a percutaneous liver biopsy was obtained. Findings on pathology were consistent with sickle cell hepatopathy with nodular regenerative hyperplasia, mild hepatocellular and Kupffer cell siderosis, and no fibrosis. He is planned for interval follow up with hepatology.

DISCUSSION:
SCD is associated with several liver complications including infarcts, abscesses, and hemosiderosis, with NRH being an uncommon complication. The proposed mechanism of NRH as it relates to SCD is due to obstructive portal venopathy resulting in areas of compromised blood flow with regenerative nodules forming in other areas of the liver to compensate for this. As it is asymptomatic with a prolonged subclinical period, it is frequently missed, however early recognition is important to avoid complications related to non-cirrhotic portal hypertension. This case highlights a very rare association between NRH and SCD.