bluuebunny/crossref_metadata_2025_split huggingface dataset:
3093 Epiphrenic Diverticula: An Added Source of Complexity in Achalasia Management
Authors: Holmes Ian , Ko Myung S. , Kouanda Abdul , Singh Aparajita , Kathpalia Priya 
Published: October 2019

INTRODUCTION:
Epiphrenic esophageal diverticula are rare and almost always associated with an underlying esophageal motility disorder. Therapeutic options for epiphrenic diverticula are evolving as per oral endoscopic myotomy (POEM) is increasingly being used for treatment of achalasia. We present two cases of epiphrenic diverticula associated with achalasia at our institution and review the clinical presentation, pathophysiology, and current management of epiphrenic diverticula.

CASE DESCRIPTION/METHODS:
Case 1 A 77 year old female presented with dysphagia. An esophagram showed two diverticula with a distal narrowing. Upper endoscopy showed two epiphrenic diverticula and a narrowed gastroesophageal junction. Manometry showed an elevated median IRP of 22.5 mmHg and pan-esophageal pressurization with all swallows, consistent with type II achalasia. A CT scan of the chest did not show any evidence of malignancy. She is currently seeking a surgical opinion for consideration of myotomy. Case 2 A 66 year old male presented with dysphagia. An esophagram showed marked dysmotility with a 1.8 cm epiphrenic diverticulum. Upper endoscopy confirmed the presence of the diverticulum. Subsequent manometry showed a median IRP of 28.8 mmHg and spastic contractions in all swallows consistent with type III achalasia. Given his type III achalasia and the smaller size of the diverticulum, he was referred for consideration of POEM.

DISCUSSION:
Esophageal diverticula can be grouped into pharyngoesophageal, mid-esophageal, and epiphrenic diverticula. Epiphrenic diverticula are “false” diverticula, with herniation of the mucosa and submucosa only, that occur due to increases in intraluminal pressure. They are associated with major esophageal motility disorders. Management of epiphrenic diverticula requires addressing the underlying motility disorder, or else the diverticula may recur after diverticulectomy. Generally, laparoscopic or combined laparoscopic/thorascopic myotomy, diverticulectomy and anterior fundoplication is required. The overall mortality rate for surgical management of epiphrenic diverticula is around 5%, with morbidity rate as high as 20%. POEM without diverticulectomy has also been described for patients who either decline surgical intervention or are not surgical candidates. As POEM technique is refined for this indication, management of epiphrenic diverticula will require close collaboration between gastroenterologists, advanced endoscopists, and surgeons for selection of the optimal treatment for each patient.
3096 Esophageal Pancreatic Acinar Ectopia—Premalignant or Benign: A Case Report and Brief Literature Review
Authors: Gboluaje Temitayo , Ajose Taiwo , Simien Melvin 
Published: October 2019

INTRODUCTION:
Esophageal Pancreatic Acinar Ectopia (EPAE) is a rare incidental endoscopy finding with reported prevalence ranging from 16% to 24% in asymptomatic patients and 3% in patients with Barrette Esophagitis, EPAE has been found in patients as young as 1 day old to incidental autopsy finding. We present a brief literature review and a case of EPAE in distal esophagus with severe dysphagia associated with active inflammation and focal metaplasia.

CASE DESCRIPTION/METHODS:
A 59 year old male with medical history of Degenerative Joint Disease (DJD), HTN, GERD, and chronic constipation presented to GI clinic with complaint of insidiously worsening dysphagia to solid food of 4 months duration. He also endorsed 30-pound weight loss and denied any other associated symptoms. He has significant family history of colon cancer. He is a current smoker with 10 pack years. His medications include Hydrochlorothiazide, Amlodipine, Lisinopril, Atorvastatin and Nexium. Physical exam revealed no significant findings in all systems, including gastrointestinal. Most recent labs including hematology and chemistry were within normal limits. An endoscopy was performed which revealed slightly irregular gastroesophageal (GE) junction, 5 × 3 cm pink rubbery mass at the GE junction which was biopsied, and an irregular gastric mucosa with biopsy obtained. The biopsy obtained from the GE junction revealed intestinal metaplasia and pancreatic acinar type tissue with no dysplasia while the biopsy from the stomach revealed numerous h-pylori, intestinal metaplasia with active chronic gastritis. At follow up appointment 2 weeks after the endoscopy, patient reported complete resolution of dysphagia and improvement in constipation.

DISCUSSION:
A review of the literature showed that Esophageal Pancreatic Acinar Ectopia (EPAE) is often an incidental finding, with prevalence in up to 24 percent of all adults and no associated symptoms in most. It has however been associated with symptoms like epigastric pain, hemoptysis, odynophagia, dysphagia, and pathologies like esophageal atresia, anaplastic carcinoma, pancreatitis, IPMN, and squamous cell carcinoma. EPAE has been documented in neonates making congenital etiology most plausible. Our case bolsters the knowledge that dysphagia, which is the most common presenting symptom in EPAE, is likely due to mass effect and our literature review revealed that most pathologies known to pancreatic tissue are possible in EPAE.
3108 Esophageal Phlebectasias: A Difficult Diagnosis to Swallow
Authors: Joshi Tejas V. , Miller Justin , Vellanki Shaitalya , Landreneau Stephen , Hutchings John 
Published: October 2019

INTRODUCTION:
In an attempt to further investigate a three-year complaint of dysphagia as well as evaluate a three-month history of diarrhea, we performed an endoscopic evaluation which revealed a unique case of esophageal phlebectasias. Phlebectasias are non-neoplastic, non-tortuous, fusiform dilatations of veins, and their pathogenesis although not fully understood. Early diagnosis of phlebectasias both its management as well as the prevention of its complications such as rupture and bleeding.

CASE DESCRIPTION/METHODS:
A 59-year-old Caucasian male with history of hypertension, GERD, hyperlipidemia, gout, obesity (BMI 40), and hypothyroidism presented to the clinic complaining of a 3-month history of loose, watery, non-bloody diarrhea that occurs 3-6 times per day with occasional nocturnal stools that occur about twice a month and is associated with abdominal cramping preceding the bowel movement. He reported a long history of GERD improved with Omeprazole and a 3-year history of substernal dysphagia to solids without regurgitation, which improved with fluid wash. Vitals were normal and his physical examination was unremarkable. Endoscopic evaluation of his dysphagia revealed numerous medium sized venous outpouchings with a localized distribution found within the lower two-thirds of the esophagus. Endoscopic ultrasound confirmed venous lakes throughout the esophagus.

DISCUSSION:
Most cases of phlebectasias found in the GI tract are asymptomatic and incidentally discovered during either GI procedures or surgeries. Guidelines on treatment have yet to reach a consensus. Surgical management of phlebectasias has more often been opted for those lesions that rapidly evolve leading to risk of rupture and subsequent hemodynamic instability, or in lesions in which the venous dilation can lend itself to forming an intramural thrombus. Phlebectasias are one of multiple vascular anomalies which can exist in the GI tract, but most of them are predominantly located in the lower GI tract such as in the stomach, small intestine, and colon. Recognizing more cases of esophageal phlebectasias can prevent complications such as severe bleeds and even bowel wall infarction. Due to scarcity of published reports, there are currently no associations of dysphagia as a complication of esophageal phlebectasias. Nevertheless, this case demonstrates the seriousness of early recognition to prevent potentially fatal complications.
3110 A Case of Reflux Esophagitis Mimicking Globus Sensation in a Patient With Cannabis Abuse
Authors: Wankhade Charudatta , Jacob Bobby , Jiyani Rucha , Karim Syed , Rizvon Kaleem 
Published: October 2019

INTRODUCTION:
Cannabis is a widely used drug of abuse in the United States (US). It is mostly commonly abused by young individuals and is known for it's psychedelic effects. Cannabis is also utilized by the medical field for a number of medicinal purposes. We present a case of a young male who presented with sudden onset dysphagia and had a significant history of marijuana abuse for several years.

CASE DESCRIPTION/METHODS:
28 year old Caucasian male with a past medical history of ADHD presented with dysphagia. The symptoms started 2 days ago. He felt like the food was stuck in his throat. Every time he attempted to drink water or liquids it regurgitated. He also reported several episodes of nausea and vomiting since the onset of his symptoms. Review of systems was negative for odynophagia, fever, drooling, weight loss, chest pain, diarrhea, constipation or acid reflux. Denied any allergies, surgical history or family history. He denied alcohol or cigarette smoking. He agreed to smoking marijunana 2-3 times per day for over 4 years. Physical examination revealed a healthy non obese male with blood pressure and pulse of 120/80 mmhg and 86 per minute respectively. Rest of his examination was unremarkable. Upper endoscopy was performed on the day of admission which revealed LA Grade D esophagitis with multiple superficial ulcers extending 5 cm from GE junction. Patient was started on proton pump inhibitors twice daily. His symptoms improved and was eventually discharged. Biopsies were suggestive of changes consistent with chronic reflux esophagitis.

DISCUSSION:
Tetrahydrocannabinol (THC) is the active ingredient derived from Cannabis Sativum. THC works by stimulating the G protein-coupled cannabinoid receptors (CBR) receptors. The presence of CBRs in the esophagus, specifically those affecting transient lower esophageal sphincter relaxations (TLESRs), offers a potential therapeutic target for treating GERD. Using Delta (9)-THC, Beaumont et al. demonstrated decreased rate of TLESRs in healthy volunteers who received 10 and 20  mg of Δ9-THC on three occasions a week apart. However, in the high dose of ΔDelta (9)-THC (20  mg) group, central activity led to increased nausea, vomiting and reflux symptoms. With ongoing discussions for the legalization of recreational cannabis use in US, we may encounter an increase in the number of reflux esophagitis cases. With this in mind, additional studies would be beneficial to determine potential risk factors for developing severe reflux esophagitis with extensive marijuana use.
3115 Bronchoscope in the Esophagus?! A Novel Technique for Esophageal Strictures Management
Authors: Patel Shruti , Desai Jiten , Jiyani Rucha , Desai Zalak , Rizvon Kaleem 
Published: October 2019

INTRODUCTION:
Benign esophageal strictures can result from long-standing GERD, ablative or radiation therapy, corrosive substance ingestion etc. Management of strictures could be very challenging. We describe a case of esophageal strictures that was managed with an innovative approach.

CASE DESCRIPTION/METHODS:
A 36-year-old Indian female with a history of esophageal strictures secondary to caustic ingestion 9 years ago presented with complaints of dysphagia. Patient underwent multiple EGD with dilatations in the early years of her stricture formation. Subsequently she was taught to perform self dilations in India, every 2 weeks to relieve dysphagia. An esophagram revealed a narrow caliber mid and distal esophagus with 3 prominent stricture points. During endoscopy an 8.8 mm gastroscope could not traverse the most proximal stricture hence a bronchoscope was used to evaluate the number and size of strictures for optimal use of pneumatic balloon catheter for dilation. The bronchoscope evaluation revealed 3 esophageal strictures at 25 cm, 30 cm and 35 cm from incisors. Serial dilations were performed with a balloon dilator and triamcinolone was then injected at the stricture site post dilation. Following this intervention she was able to defer dilatation for 6 weeks. Using a Bronchoscope a second session of dilatation and triamcinolone injection was repeated 6 weeks later. Therapy was required for one of the three strictures with the others having healed well. Patient has not been performing self dilations since her first EGD and continues to be asymptomatic.

DISCUSSION:
Caustic ingestion and its gastrointestinal sequelae such as stricture formation have been an important public health concern for decades. Damage and complications depend on several aspects: substance concentration and pH, length of time of tissue contact and amount ingested. The primary treatment of a caustic esophageal stricture is endoscopic dilatation, however sometimes management could be challenging. Using a bronchoscope (thin caliber scope), the high grade strictures in our patient were traversed and evaluated optimally prior to execution of the treatment modality. In our extensive literature review, a bronchoscope has never been used before for managing high-grade strictures, which makes our case unique. We believe that this new technique of utilizing a bronchoscope for evaluation of high-grade strictures can provide more targeted therapeutic approach and superior management to the patient.
3118 Case of Capecitabine-Induced Diarrhea Leading to Renal Failure Requiring Hemodialysis
Authors: Arroyo Yadis M. , Narasimha Shruthi , Bertran-Rodriguez Carlos E. , Pagan Andrea 
Published: October 2019

INTRODUCTION:
Capecitabine is a cytotoxic oral prodrug of 5-fluorouracil used as a chemotherapeutic adjuvant in the treatment of colorectal cancer. The most common adverse effects reported are hand-foot-syndrome and diarrhea. Incidence of diarrhea has been reported in up to 67% of patients. The pathophysiology of capecitabine induced diarrhea is not well understood with most cases being attributed to drug toxicity and overexpression of inflammatory cytokines. Chemotherapy induced diarrhea (CID) can be deleterious and, in some cases, life threatening. The subsequent case presents the development of acute renal failure requiring hemodialysis after treatment with capecitabine.

CASE DESCRIPTION/METHODS:
Case of a 50-year-old man with stage 3B T2N2M0 moderately differentiated adenocarcinoma of the rectum who presented with non-bloody diarrhea after recently starting his first chemotherapy treatment with CAPOX-Oxaliplatin and Capecitabine. Laboratory studies were significant for acute kidney failure with creatinine of 2.9 mg/dL and non-anion gap metabolic acidosis with bicarbonate of 18 mmol/L. Physical examination was unremarkable. Infectious workup for diarrhea was negative. Patient's renal function progressively worsened and ultimately required hemodialysis. After a negative colonoscopy and multiple bowel regimens, including lomotil, questran, octreotide and budesonide, his diarrhea was deemed to be secondary to Capecitabine therapy and only started to resolve after initiation of budesonide. Upon interval follow up with gastroenterology his diarrhea had completely resolved, and creatinine was at baseline.

DISCUSSION:
Grade 3–4 diarrhea occurs in 11.4% of patients treated with capecitabine monotherapy. However, when used in combination with other chemotherapeutic drugs also known to cause diarrhea such as oxaliplatin, the incidence increases to 18.2%. In general, treatment is conservative and limited to IV hydration, electrolyte replacement, and medications such as, loperamide and octreotide. However, in cases with standard treatment failure, it has been proven that budesonide effectively reduces the effects of 5-FU on the intestinal mucosa. In the literature, no other cases have been reported of acute renal failure requiring hemodialysis after treatment with capecitabine. Given the unpredictability of the effects of chemotherapy induced diarrhea and its potential to increase morbidity and mortality, it is essential to maintain close monitoring of such patients and provide adequate supportive treatment.
3121 Spontaneous Breakage and Antegrade Enteral Migration of Jejunal Extension Tubing
Authors: Goens Donald , Berger Matthew , McDonald Edwin K. 
Published: October 2019

INTRODUCTION:
Gastroenteric tube feeding can provide essential nutrition for patients with neurologic or mechanical dysphagia. Many patients undergo pre-pyloric feeding; however, some patients require post-pyloric feeding through jejunal access. These present additional challenges in placement with potential for complications. Here we discuss a rare complication of a jejunal extension portion of a gastrojejunostomy (G-J) tube separating and becoming a foreign body.

CASE DESCRIPTION/METHODS:
A 77-year old woman with a past medical history of rheumatic heart disease with mitral stenosis and pulmonary hypertension (pHTN) was admitted for acute decompensated pHTN. Three months prior the patient had underwent radiologic percutaneous placement of a pull-type gastric-tube (G-tube) for dysphagia due to severe deconditioning. One week later she developed gastroparesis and the tube was exchanged under fluoroscopy with a 9-french G-J tube extension. Upon admission patient was tolerating tube feeds without complication and underwent intravenous diuresis for her pHTN exacerbation. On hospital day seven she reported onset of abdominal pain and bloating. Physical exam noted new right-upper quadrant tenderness and mild distention, G-J tube insertion site appeared normal without leakage or skin breakdown. Abdominal x-ray showed the jejunal extension tubing had separated from the G-tube balloon insertion and was visualized projecting coiled over right lower quadrant (Figure 1). Tube feeds were held and the gastroenterology service was consulted. At time of re-examination abdominal symptoms had resolved. Given the positioning of the tubing, serial abdominal imaging and supportive measures of daily suppositories to facilitate spontaneous passage by rectum were recommended. The patient was restarted on tube feeds through the remaining G-tube without complication. Ultimately the jejunal extender proceeded through the colon (Figure 2) and passed by rectum 5 days later without complication (Figure 3).

DISCUSSION:
The placement of jejunal extensions through existing gastrostomy tubes is typically a well-tolerated procedure and antegrade migration of jejunal tubing is rare. In this case the jejunal tubing somehow separated from its gastrostomy tube anchor. In the event of this rare complication it is reasonable to monitor for spontaneous passage with serial imaging as demonstrated in this case, with consideration for surgical exploration or endoscopic retrieval if there is non-progression of the tube or an associated complication.
3122 The Adventures of a Missing Denture
Authors: Rojas Patricia Guzman , Gonzaga Ernesto Robalino , Henriquez Richard , Vergeli-Rojas Jeannette 
Published: October 2019

INTRODUCTION:
Foreign body ingestion is a common clinical situation, and most of the ingested foreign bodies (80%) pass spontaneously through the gastrointestinal tract. Though, if an impaction is present, it usually occurs in the anatomic constrictions or angulations of the GI tract.

CASE DESCRIPTION/METHODS:
We present a 56 y.o. man with PMH of reflux and diverticulosis. The patient presented to the ED complaining of swallowing his dental implants 5 hours prior to admission. He denied having abdominal pain, nausea, vomiting after the accidental ingestion. Physical exam showed a soft, non-tender abdomen and oral examination revealed a 4 cm × 1 cm denture missing that corresponded to the teeth implant. CT abdomen was done showing an ingested denture located at the gastric area (Figure 1: left panel). GI was consulted and an EGD was performed the morning after admission. The EGD was unremarkable and no dentures were found, for this reason a repeated abdominal serial xrays were ordered to monitor the foreign body. The X-Ray (Figure 1: middle panel) displayed the denture at the region of the distal ileum. In light of failure to pass spontaneously, a colonoscopy was performed the next day. At the colonoscopy, the dentures were found in the cecum (Figure 2) and these were retrieved without immediate complications.

DISCUSSION:
Although dental ingestion is not uncommon, there are several risks factors that were absent in our patient, like edentulism, psychoneurological deficit, and abnormal level of consciousness. Furthermore, this patient was a middle-aged healthy adult, completely alert and able to report any sudden GI symptom. Regarding the management of ingested foreign bodies, timing of the intervention depends on the size, shape, content and anatomic location of these, being the esophagus the most common site for impaction, and if occurs, this warrants an emergent endoscopy. Objects longer than 6 cm are unlikely to pass the duodenum and they need urgent removal. In our case, the foreign body had a maximum diameter of 4 cm; reason why an EGD was not emergent. A colonoscopy was performed in view of the possibility that the dentures were located at the IC valve, which is the most frequent place of perforation. We present this patient in order to elucidate a non-complicated foreign body ingestion, that needed endoscopic removal by means of a colonoscope. Furthermore, we would like to emphasize the safety of monitoring foreign objects with blunt edges and less than 6 cm in diameter.
3123 Massive Pneumoperitoneum Following G-Tube: Is Severe Constipation a Risk Factor?
Authors: Senatore Frank , Dellatore Peter , Seril Darren 
Published: October 2019

INTRODUCTION:
Pneumoperitoneum has been shown to occur in approximately 5% of patients undergoing gastrostomy tube (G-tube) placement via esophagogastroduodenoscopy (EGD). Of those, only half have clinically significant symptoms normally in the setting of moderate to large pneumoperitoneum. We report a case of massive pneumoperitoneum presenting as an acute abdomen without overt perforation.

CASE DESCRIPTION/METHODS:
An 80-year-old male with recently diagnosed piriform sinus squamous cell carcinoma was directly referred to our endoscopy unit by his oncologist for G-tube placement given plans for chemoradiation. He was asymptomatic. We performed an EGD which revealed normal gastric and duodenal mucosa. A site was located in the gastric body and the stomach was insufflated revealing excellent transillumination and one-to-one manual external pressure. A 20Fr G-tube was successfully placed via the pull-guidewire technique. Post procedure, he was asymptomatic and tolerated an oral diet. Next day he presented to the emergency room with severe abdominal pain and distention. He was afebrile, tachycardic and had a rigidly distended abdomen. White blood cell count was 11.8 and lactic acid was 2.3. Computed tomography (CT) scan showed large free intraperitoneal air concerning for perforation. He was given antibiotics, kept NPO and seen by general surgery. Review of the CT scan showed the G-tube bumper in the stomach with oral contrast filling it without extravasation and dense stool burden filling the entire colon (Figure 1). Delayed images showed contrast in the small and large intestine without any extravasation. Polyethylene glycol solution was initiated via the G-tube resulting in numerous bowel movements and significant symptom improvement. Imaging performed 48 hours after revealed resolution of pneumoperitoneum and stool burden (Figure 2). He was discharged on a bowel regimen and continued to be asymptomatic at follow-up.

DISCUSSION:
This case illustrates the importance of clinical acumen when evaluating patients' post-procedure, as this patient's initial imaging and exam findings could have resulted in an unnecessary surgery. Further, we hypothesize insufflation during EGD in a patient with severe constipation can result in a high-pressure gradient driving air into the peritoneum via the iatrogenic perforation site. This case emphasizes caution in performing G-tube placement in patients with severe constipation and also highlights the potential pitfalls of a direct referral endoscopy system.