bluuebunny/crossref_metadata_2025_split huggingface dataset:
1685 Endoscopic Fistulectomy of an Obstructive Esophagogastric Mucosal Bridge
Authors: Vachaparambil Cicily , Mekaroonkamol Parit , Cai Qiang 
Published: October 2019

INTRODUCTION:
Esophageal mucosal bridges are rare complications from many causes including congenital abnormalities, radiotherapy, sclerotherapy, nasoenteric feeding tubes, or Crohn’s disease. Mucosal bridges are made of smooth muscle crossing gastrointestinal lumen and resulting in a double barrel appearance on endoscopy. Pathogenesis may involve mucosal undermining by ulceration followed by healing, re-epithelialization of the mucosal undersurface, and formation of a mucosal tube attached to the non-ulcerated wall. Therefore, chronic, repetitive ulcerations and subsequent healing may lead to bridge formation. Another theory is that inflamed walls of esophagus contacting one another allows granulation tissue to form adhesions resulting in a mucosal bridge. This could explain fistula formation in inflammatory bowel disease.

CASE DESCRIPTION/METHODS:
A 68-year-old woman presented with a 6-year history of progressive solid food dysphagia and gastroesophageal reflux. Her past surgical history was significant for laparoscopic band surgery complicated by gastric band erosion into the stomach at the gastroesophageal junction that required subsequent gastric band removal and omental flap reinforcement of the gastric perforation nine years prior to presentation. A diagnostic upper endoscopy revealed an esophageal fistula at the gastroesophageal junction and biopsies at the junction showed chronic inflammation without dysplasia. The upper endoscope was advanced to the gastroesophageal junction at 37 cm from the entry site. Proximal to the gastroesophageal junction, two esophageal lumens were seen leading to the gastric lumen due to a thick mucosal bridge causing partial obstruction to the stomach. First, four hemostatic clips were placed at both ends of the stalk before mucosal incision to prevent bleeding. The bridge was grasped with forceps and fistulectomy was performed with a needle knife to incise the mucosal bridge between the clipped portion using electrocautery. On post-operative follow-up at week 6 and 12, the patient had complete resolution of dysphagia and no demonstrated recurrence of mucosal bridge formation.

DISCUSSION:
This is an unusual case of an esophagogastric fistula from a delayed adverse event of laparoscopic gastric band placement even after band removal and corrective surgery that caused dysphagia. It was successfully treated with endoscopic fistulectomy using hemostatic clips and a needle knife under direct visualization. This method has proven to be effective with no reported recurrences.
Watch the video: http://bit.ly/2Y0JNws.
1694 Endoscopic Ultrasonography With Fine-Needle Aspiration in the Diagnosis of Metastatic Rectal Adenocarcinoma in Left Atrium
Authors: Koneru Gopala K. , Shah Ishani , Kantamaneni Vamsi , Peck Joshua R. 
Published: October 2019

INTRODUCTION:
Endoscopic ultrasonography(EUS) of the mediastinum with the use of fine needle aspiration(FNA) or biopsy can be used to characterize lesions that are within or adjacent to the esophageal wall, posterior and inferior mediastinum with minimal risk to the patient. EUS is an underutilized tool for identifying mediastinal masses and can help guide clinical decision making in patients with concerning lesions found on non-invasive imaging modalities.

CASE DESCRIPTION/METHODS:
A 71-year-old male with history of adenocarcinoma of the rectum with metastases to the liver and lung was treated with surgical resection and adjuvant chemotherapy. Patient responded well and was under regular surveillance when a new irregularly shaped abnormal soft tissue density measuring approximately 5.4 × 3.0 cm adjacent to the aorta and esophagus appearing to invade into the left atrium (Figure 1a) was found on a CT scan and confirmed on PET imaging. These findings favored rectal metastatic disease over thrombus but could not definitively rule out a new carcinoma. For that reason, an endoscopic ultrasonography was performed to determine the nature of the mass. A curvilinear array echoendoscope was used to visualize a 36 × 30 mm exophytic lesion within the left atrium which extended into the posterior mediastinum (Figure 2). Using Doppler to identify a vessel-free path, a 25-gauge needle was passed under ultrasound guidance through the esophagus and directly into the mass with the use of an endoscopic fine needle biopsy (FNB) device for three passes. Histopathological examination confirmed adenocarcinoma (Figure 3) and immunophenotype was compatible with colorectal primary which ruled out a pulmonary adenocarcinoma.

DISCUSSION:
The patient was determined to not be a surgical candidate due to the location of the mass and high risk nature of the surgery. The multidisciplinary team’s consensus was to repeat chemo-adjuvant therapy since he had responded so well previously. He received treatment and had follow up imaging six months after EUS diagnosis which showed decrease in size (Figure 1b) and activity of the mass. He is planned to have have stereotactic body radiation therapy to further decrease the size of the atrial mass. This case demonstrated how EUS with the use of FNA is a helpful tool in the prompt evaluation and confirmation of a mediastinal mass which allowed all physician’s involved in the care of the patient to develop and implement a treatment plan quickly.
Watch the video: http://bit.ly/2Giu99S.
1696 Is It Technically Feasible to Use Duodenoscopy in Endoscopic Submucosal Dissection for the Recurrent Laterally Spreading Ampullary Adenomas?
Authors: Li Wen , Wang Zikai , Liu Fang , Wang Xiangdong , Meng Jiangyun , Wang Jun 
Published: October 2019

INTRODUCTION:
The management strategies of recurrent ampullary adenomas after endoscopic papillectomy is still a controversial issue regarding the best modality for treatment. The aim of the study is to assess the feasibility, efficacy and safety of duodenoscopic submucosal dissection (DESD) for the recurrent laterally spreading ampullary duodenal lesion.

CASE DESCRIPTION/METHODS:
We prospectively enrolled two patients with recurrent laterally spreading ampullary duodenal adenomas after successful papillectomy. Following marking the resection borders of the lesion using a Dual knife, a submucosal cushion is created by injecting a mixture of saline solution, methylene blue and adrenaline. A circumferential incision followed by submucosal dissection was performed using Dual knife and IT knife, then the lesion was resected using an electric snare. Hemostasis was applied using coagulation grasper during the procedure. Following dissection ERCP with biliary and pancreatic stenting was performed. Finally closure of the resection site was achieved using Endo-clipping in order to prevent complications such as secondary hemorrhage and delayed perforation. DESD followed by biliary and pancreatic stenting was performed successfully for two patients with recurrent laterally spreading ampullary duodenal adenomas. Table 1 shows the procedure details for the initial papillectomy which showed En-bloc resection of both lesions. Table 2 shows detailed current characteristics and procedure details for the recurrent lesions. Figures 1 and 2 Show endoscopic procedures. The average total procedure time was 95.5 mins, and the procedure time of DESD and ERCP was 38.5 mins and 15.5 mins respectively with no serious intra-or post procedure complication. The histopathological examinations revealed tubulovillous adenoma with negative resection margins in case 1. Unfortunately specimen of case 2 was not retrieved successfully. Follow up at the third, sixth and twelfth month showed no residual or recurrent lesions in ampullary areas, biopsy of resection site showed inflammation with absence of adenomatous tissues in both cases.

DISCUSSION:
In conclusion, DESD is technically challenging, potentially effective and curative for laterally spreading duodenal ampullary adenomas within 2 cm in diameter. It should be performed cautiously in selected patients by experts with abundant experience in performing not only ESD but also ERCP.
Watch the video: http://bit.ly/2Y4dE77.
1697 The Safety and Efficacy of Endoloop Ligation (“Loop-and-Let-Go”) of a Very Large Jejunal Lipoma
Authors: Ramsey Mitchell L. , Krishna Somashekar 
Published: October 2019

INTRODUCTION:
Lipomas can occur anywhere throughout the gastrointestinal tract and can range widely in size. When symptomatic, these lipomas require removal, and several techniques have been described depending on the size of the lesion. Recently, a method utilizing an endoloop ligation has been proposed and validated for use in colonic lipomas. However, there remains a lack of literature on the safety and efficacy of endoloop ligation for the removal of symptomatic lipomas in the small intestine.

CASE DESCRIPTION/METHODS:
A 55-year-old male with a history of neurofibromatosis, prior prostate cancer, and tobacco use presented for evaluation of melena. He underwent an upper endoscopy which was reportedly normal and was transferred to our center for consideration of small bowel endoscopy. He continued to have melena and labile hemoglobin. A push enteroscopy revealed a long, submucosal lesion in the proximal jejunum with several areas of ulceration which were presumed to be the source of his bleeding. The mass was biopsied, and pathology was consistent with a lipoma. Subsequently, the patient underwent EUS and endoloop ligation. A video from this case is submitted to demonstrate the proper use of endoloop ligation of a large lipoma in the small intestine. Following placement of the endoloop ligature, the patient had no further bleeding and a follow-up enteroscopy one month later revealed complete loss of the lipoma with unremarkable appearing mucosa.

DISCUSSION:
In this case, we demonstrate that endoloop ligation is a safe technique for the removal of symptomatic large lipomas in the small bowel. In the video, we demonstrate how to apply the endoloop ligature to such a lesion effectively.
Watch the video: http://bit.ly/2JSdmLE.
1699 Stent Gone Rogue: Endoscopic Removal of a 3-Year-Old Embeded Cystgastrostomy Stent
Authors: Chittajallu Vibhu , Simons-Linares Roberto , Walsh R. Matthew , Chahal Prabhleen 
Published: October 2019

INTRODUCTION:
We present a case of endoscopic removal of a delayed SEMS migration into the retroperitoneum, resulting in a perisplenic abscess and embedding of the SEMS into the gastric and retroperitoneal wall.

CASE DESCRIPTION/METHODS:
A 60-year-old man with idiopathic acute necrotizing pancreatitis complicated by walled-off pancreatic necrosis (WOPN) status post EUS-guided cystgastrostomy 3 years prior, presented with 3 weeks of worsening chronic abdominal pain and fever. Previous cystogastrostomy was performed with a through the scope 18 mm × 60 mm fully covered self-expandable esophageal metal stent (SEMS). Plan was to have SEMS removed after WOPN resolution; however, patient was lost to follow up. Abdominal CT scan revealed fluid collection in pancreatic tail measuring 4.8 × 1.9 cm and cyst-gastrostomy stent in place, splenomegaly measuring 15.5 cm with a perisplenic subcapsular collection along the lateral and superior splenic margin measuring 13.3 × 1.9 cm, thin fluid tract/collection extending from the pancreatic tail with more superior extension to questionably communicate with perisplenic collection. The 3-year-old SEMS was attempted to remove with a new through the scope fully covered 18 mm × 60 mm esophageal SEMS (Taewoong medical) but failed. Following, a new 20 mm lumen-apposing metal stent (LAMS) (Axios, Boston Scientific) stent was deployed within the embedded 3-year-old SEMS and it was secured to the embedded stent with standard clipping (Cook Medical), and CT abdomen 3 weeks after discharge noted improvement of perisplenic fluid collections. Follow up EGD/EUS allowed successful removal of 6F drainage catheter and inner Axios stent with rat tooth. After prolonged efforts, utilizing snare, biopsy, and piecemeal extraction, the embedded 3-year-old SEMS with wire struts and lattice fixed into the gastric wall and retroperitoneum was removed with no fragment remaining that was confirmed multiple times on endoscopy and fluoroscopy. Finally, Patient remained in good health without recurrence of symptoms at 6-months follow up in the outpatient clinics.

DISCUSSION:
This is the first case report of successful endoscopic removal of a 3-year-old embedded cystgastrostomy stent.
Watch the video: http://bit.ly/2Lvc78C.
1700  Low Back Pain: An Unusual Initial Presentation of Esophageal Adenocarcinoma
Authors: Hawa Fadi , Al Hillan Alsadiq , Al-Banaa Kadhim , Gunaratnam Naresh T. , Yazdani Ali 
Published: October 2019

INTRODUCTION:
Esophageal cancer is the sixth most common cancer worldwide that is associated with a poor prognosis. Clinically, dysphagia and weight loss are the most common presentations. However, non-specific symptoms of distant metastatic disease might be the initial presentation which provides a diagnostic challenge and delay in management. We describe a case of an unusual presentation of esophageal cancer with acute low back pain secondary to vertebral compression fracture without gastrointestinal symptoms.

CASE DESCRIPTION/METHODS:
A 51-year-old male with tobacco use disorder but otherwise unremarkable medical history, presented to the clinic with acute onset non-traumatic right flank pain and low back pain. Patient had no gastrointestinal symptoms. Physical examination and baseline laboratory data yielded no pertinent findings. Computed Tomography scan of the abdomen showed L2 vertebral body compression deformity. Radiography and Magnetic Resonance Imaging of the lumbar spine were concerning for an acute L2 pathological compression fracture. Therefore, patient had a core biopsy of the L2 vertebral body which revealed metastatic adenocarcinoma favoring an upper gastrointestinal primary tumor. Accordingly, patient underwent an upper endoscopy which revealed a non-lumen occluding distal esophageal mass. Endoscopic Ultrasound revealed a 7 × 8 mm lymph node adjacent to the pancreatic body. Biopsy of the mass and fine needle aspiration of the lymph node were consistent with Stage IV esophageal adenocarcinoma. Patient is currently undergoing palliative chemotherapy and radiation therapy.

DISCUSSION:
Esophageal cancer is often asymptomatic in early stages and patients present with progressive dysphagia at advanced stages, when the esophageal lumen is less than 13 mm. Initial presentation of esophageal cancer with symptoms of distant metastatic disease without gastrointestinal symptoms have been rarely described in the literature. Our patient’s lack of supportive gastrointestinal symptoms and atypical presentation with low back pain, provided a diagnostic challenge. However, L2 vertebral body biopsy was the key in establishing the diagnosis of esophageal cancer. This case highlights the atypical initial presentation of esophageal cancer as a metastatic disease which can present with myriad of symptoms unrelated to the primary tumor. Therefore, when esophageal malignancy is suspected, histopathological examination of a possible metastasis might be the only window towards diagnosing the primary esophageal cancer.
1702 Acute Esophageal Necrosis: A Rare Complication of Long-Standing Alcohol Abuse With Severe Hypoperfusion
Authors: Serrano Alexis , Shah Reshma , Brizell Kimberly , Kudelko Marc , Halleman Christopher D. 
Published: October 2019

INTRODUCTION:
Acute Esophageal Necrosis, the “black esophagus”, is dark pigmentation of the esophagus with histologic mucosal necrosis that presents with symptoms of bleeding from the upper GI tract. AEN itself is not a poor prognostic factor. AEN in combination with multiple comorbidities raises mortality up to 32%. Risk factors include alcohol abuse, advanced age, male gender, advanced malignancies, hypertension, coronary artery disease, renal disease, and diabetes mellitus.

CASE DESCRIPTION/METHODS:
A 71 yr old male with medical history of CKD4, CAD, HTN, HLD, Barrett’s esophagus, ulcerative esophagitis, and alcohol use presented with hematemesis, abdominal pain, and melena that began three days prior. Patient was hypotensive and tachycardic with a hemoglobin of 4.8g/dL. Pt was administered multiple unity's of pRBCs, IV PPI, IV Octreotide, and IV fluid resuscitation. Due to hemodynamic compromise, a left IJ CVC was placed and vasopressors started. The GI team was consulted. Emergent EGD revealed circumferential esophagitis with ulcerations, adherent clots, and large areas of black mucosal discoloration. Broad spectrum antimicrobials initiated. A gastrograffin study was obtained without extravasation noted. Patient was diagnosed with pyelonephritis and transitioned to culture sensitive antimicrobial therapy; still requiring vasopressors and blood products due to multifactorial shock. Given severity of illness and grim prognosis, the patient’s family elected for comfort care.

DISCUSSION:
AEN is a rare condition with an etiology thought to be multifactorial-to a low flow state from watershed distribution and corrosive injury from gastric contents due to esophagogastroparesis and gastric outlet obstruction resulting in decreased function of mucosal barrier systems and impairment of repairing mechanisms. Visualization via EGD of circumferential black mucosal necrosis with an abrupt stop at the GE junction is diagnostic. If circumferential necrosis is seen, immediate withdrawal of the scope should be performed. In patients with patchy necrosis, the clinician may be able to continue with endoscopy. Treatment is supportive with IVFR, IV PPIs, blood transfusions, carafate, and most importantly treatment of the underlying disease state. Complications include esophageal perforation, mediastinal infections with abscesses, esophageal strictures, esophageal stenosis, and death. General Surgery should be consulted for possible intervention. After the patient exhibits improvement, repeat endoscopy should be performed.
1707 Sorafenib-Induced Severe Candida Esophagitis
Authors: Tageldin Omar , Mansoor Muhammad Sohail , Parsa Nour 
Published: October 2019

INTRODUCTION:
Candida species are a part of normal GI flora however some patients, especially during immunocompromised state can develop Candida esophagitis (CE). Sorafenib is a tyrosine kinase inhibitor commonly used for treatment of renal cell and hepatocellular carcinoma (HCC). We report one of the most severe cases of CE following Sorafenib.

CASE DESCRIPTION/METHODS:
An 84-year-old man was admitted for a 2-week history of solid food dysphagia with nausea, chocking and regurgitation following food intake. His medical history included type 2 diabetes mellitus and stage IV (T3N0M1) metastatic HCC. Patient had been taking Sorafenib 400mg twice daily for the last 6 months and recently received palliative radiotherapy (RT) for a pathologic pelvic fracture due to bone metastasis. Patient denied any vomiting, odynophagia, anorexia, fever, chills, abdominal pain, diarrhea or constipation. On clinical examination, he had normal vital signs, appeared thin and cachectic, had oral thrush underneath artificial dentures while the rest of the clinical examination was unremarkable. His lab-work showed borderline leukocytosis of 11.9 103/µL, mild anemia with Hb of 10.5 g/dl, and normal electrolytes, renal function and liver integrity enzymes. He underwent an esophagogastroduodenoscopy (EGD) which interestingly showed esophagus completely lined with thick whitish adherent plaques, diffuse atrophic gastropathy and normal duodenum. Despite the esophagus having no tortuosity, rings or strictures, it required considerable amount of force to advance the endoscope through the copious amount of exudate in the esophagus which would explain the patient’s dysphagia. We obtained biopsy and brushing from esophagus which revealed abundant inflammatory cells and fungal organisms consistent with Candida species. Patient was given a loading dose of 400 mg of Fluconazole followed by 200 mg daily for 21 days. After completion of therapy, patient’s symptoms had improved, and he was tolerating a regular diet.

DISCUSSION:
Upon literature review we found one case series of 2 patients mentioning CE as a side effect with the use of Sorafenib. Unlike above case series in which patients developed CE soon after initiation of Sorafenib, our patient developed symptoms after being on it for 6 months. Physicians should be aware when using Sorafenib that it can induce an immunosuppressive state with an increased risk of CE. Delayed diagnosis and subsequent treatment may affect the nutritional status and subsequently the overall survival in these patients.
1725 A Case of Latin American Female Diagnosed With Esophageal Adenocarcinoma on Brush Cytology Biopsies
Authors: Multani Monica , McDonald Emmanuel , Ponce Fernanda , Sharma Radhika , Sobrado Javier 
Published: October 2019

INTRODUCTION:
In 1975, the incidence of esophageal adenocarcinoma (EAC) was 0.4 cases per 100,000. In 2009, the incidence had risen by 5 fold to 2.58 cases per 100,000, making it one of the fastest growing cancers at this time. Esophagoduodenoscopy (EGD) is the gold standard for diagnosing Barrett’s esophagus (BE), which is a precursor to EAC. With the advent of new techniques of brush cytology sampling, there is potential to broaden our technology and our screening criteria for prevention. We present a rare case of a Latin female who was diagnosed with EAC after goblet cells were incidentally found on brush cytology.

CASE DESCRIPTION/METHODS:
A 73 year old Latin female with history of hiatal hernia, and H. Pylori presented with heartburn and abdominal pain. The EGD showed foveolar dysplasia at the gastric-esophageal junction. Wide Area Transepithelial Sample Biopsy With 3-Dimensional Computer-Assisted Analysis (WATS3D) showed goblet cell metaplasia. Repeat WATS3D confirmed these results and repeat forceps biopsy showed high grade dysplastic glands consistent with a well differentiated EAC. She underwent endoscopic ultrasound with biopsy and it was staged as T3N2Mx. She had a mucosal resection performed which showed poorly differentiated EAC and was referred to oncology.

DISCUSSION:
It is predicted that between 2011 and 2030, deaths related to EAC will double the number of those that died between 1991 to 2010. Some studies have shown increased detection rates of EAC precursors including those of BE and esophageal dysplasia (ED). For example, a 2010 study concluded that WATS3d brush biopsy allowed for substantial increases in the detection rates of BE by 39.8% and ED by 87.5%. Another 2017 study revealed an increase of 83% for BE and 88.5% for ED. Thus, cytology brush biopsies can help to diagnose high grade dysplasia and/or cancer with greater than 80% sensitivity and 95% specificity. It is also important to note that for women, the future incidence and mortality rates are also expected to rise in 2030 by approximately 9 times. The population we screen for BE is in white males over 50 who are symptomatic and with risk factors for BE or EAC. However, this is a rare case of a latin female that would not have fallen under these screening guidelines. Because of the rising incidence with worsening mortality contributing to the overall rise in EAC cases, we believe that it is imperative to broaden our screening criteria and to implement new tools such as brush cytology biopsies to a broader population as well.