bluuebunny/crossref_metadata_2025_split huggingface dataset:
2106 Granulomatous Lung Disease in a Patient With IBD: What Is It?
Authors: Padial Doble Ian C. , Torres Esther 
Published: October 2019

INTRODUCTION:
When a patient with inflammatory bowel disease (IBD) presents with respiratory complaints the differential diagnosis includes many conditions unrelated to IBD. Extra-intestinal manifestations (EIM) involving the lungs are relatively uncommon. Biologics for IBD can also have secondary effects including pulmonary toxicity and infectious complications.

CASE DESCRIPTION/METHODS:
A 48 y/o female nurse with history of bronchial asthma and hypertension was diagnosed with ulcerative pancolitis in 2005. In 2017, she was started on adalilumab (ADA) after repeated use of steroids and intolerance to azathioprine. ADA was discontinued after one year due to multiple subcutaneous nodules and fever that cleared on drug discontinuation. Differential diagnosis included erythema nodosum and hidradenitis. She was found with (+) quantiferon despite negative tuberculin (TB) skin test and chest x ray and was treated for latent TB with isoniazid for one year (04/18-04/19). Four months later (08/18), she was started on infliximab (IFX) with good response. On 01/19, an incidental left pleural effusion was found and she underwent thoracentesis. In 03/19, she developed night sweats and pleuritic chest pain. Chest x-ray demonstrated a large right pleural effusion. Bronchoscopy and pleural biopsy showed necrotizing granulomas negative for AFB and GMS. IFX was discontinued and she was started on high dose steroids with little improvement. Chest CT preformed on 05/19 demonstrated bilateral effusions and multiple upper lobe and centrilobar noncalcified opacities with tree in bud appearance. Bronchoscopy with lung biopsy showed multiple noncaseating granulomas negative for AFB and GMS.

DISCUSSION:
The differential diagnosis in this patient includes lung involvement of IBD, vasculitis, infections, drug reaction and concurrent primary sarcoidosis among others. Vasculitis and infections have been excluded, and the lack of improvement after IFX discontinuation and steroids suggests IFX is not the cause. However, several cases of sarcoidosis associated to anti-TNF drugs have been reported and drug-induced sarcoidosis remains a high probability. Pulmonary EIM is also still a possibility in spite of clinical remission of UC.This case report demonstrates the importance of remaining aware of possible rare EIM of IBD and also of other rarer complications in this new age of biologics. Early diagnosis and effective treatment are important to prevent complications and improve outcomes for these patients.
2115 Novel Use of a Bare Metal Self Expanding Stent for Biliary Drainage Following Hepatic Cystectomy
Authors: Anderson Jeremy , Truscello David , St. Michel David , Sebastian Eli 
Published: October 2019

INTRODUCTION:
Bile leak following a partial hepatectomy or cystectomy is not uncommon. Perihepatic collections following surgery are largely managed in two ways: Image-guided percutaneous drainage or endoscopic retrograde cholangiopancreatography (ERCP). Intervention during ERCP may include sphincterotomy with placement of a plastic 7 or 10 Fr stent. While metal stents have been indicated in cases of biliary stenosis, no cases to date have presented the use of a covered self-expanding metal stent (cSEMS) for maximizing drainage. We present the case of a 78 yo female with polycystic liver disease who had a cSEMS placed after the formation of a perihepatic bile collection following a liver cyst resection.

CASE DESCRIPTION/METHODS:
This is a 78 year old female with a history of polycystic liver disease (PLD). Patient had previous resection of large liver cyst approximately one year earlier. She developed recurrence of a large liver cyst requiring surgical intervention and underwent laparoscopic liver cyst resection of the right lobe. Within one week of surgery, increased biliary drainage prompted a return to the hospital. Gastroenterology was consulted and took the patient for ERCP. A 10 mm covered self-expanding metal stent was placed in the common bile duct under direct visualization of the sphincter in conjunction with fluoroscopy imaging. This was done instead of Fr stents with the expectation that a large metal stent would afford improved biliary drainage and divert away from parenchymal leakage. The patient did well following the procedure and was discharged with percutaneous drain in place. Follow up CT of the abdomen and pelvis was performed 5 weeks following placement of biliary stent. The study demonstrated that the drain and stent were in good position. There was an interval decrease in size of perihepatic collection.

DISCUSSION:
A bile leak is often found due to increased output or change in fluid output from a surgical drain as was seen in this patient. If endoscopic intervention is undertaken, current practice involves placement of plastic stents. Literature demonstrates the use of cSEMS in patients who present with biliary stricture secondary to malignancy. Comparisons of plastic versus metal stents in this population show migration rates were lower in the metal stent arm. While there was no comparison of their drainage capabilities, they do demonstrate the feasibility of cSEMS placement in other patient populations where plastic stent placement has been standard.
2124 Piling Gold in the Prostate
Authors: Hanjar Abrahim , Kumar Manoj , Fahmawi Yazan , Mizrahi Meir 
Published: October 2019

INTRODUCTION:
Precisely steered radiation beams to tumors attenuates the radiation to contiguous tissues. Image-guided radiation therapy which uses implantable radiographic markers, or fiducial markers (FMs), serving as reference points to accurately delineate tumor location. This is particularly important in the prostate, a moving target whose positioning depends on the dynamics of its neighboring bladder and rectum. Traditionally, implantation of FMs into the prostate has been an invasive surgical procedure with potential risks. With the evolution of advanced endoscopic ultrasound (EUS), FMs placement under EUS guidance is rapidly gaining interest as a novel therapeutic technique. Below is a case series discussing our experience with this procedure.

CASE DESCRIPTION/METHODS:
Case Series: Technique- Conscious sedation was used. Transrectal EUS was performed by using a curvilinear-array echoendoscope. The base and the apex of the prostate were identified as a hypoechoic, round structure with respect to rectum and seminal vesicle location. Using a 22-gauge needle, 4 fiducials were placed in a 4-quadrant fashion (bilateral base and apex) with at least 1 cm of distance between the fiducials. 1st case: 60-year-old AAM with prostate cancer was referred for fiducial placement for stereotactic body radiation therapy (SBRT). FMs were placed under EUS guidance. Patient completed his radiation treatment and did not report any procedure related complications during follow ups. 2nd Case: 73-year-old male on active surveillance for low risk prostate cancer for several years was elected for SBRT due to recent elevation of prostate specific antigen (PSA). FMs were placed under EUS guidance. Patient completed the SBRT successfully. Post treatment, patient had episode of acute prostatitis and cystitis managed with Analpram and Flomax and was linked as unrelated to FMs placement. 3rdcase: 53-year-old male with prostate adenocarcinoma underwent EUS guided FMs placement. He completed SBRT successfully. On follow-up visits he reported some burning on urination that was controlled with Pyridium, minimal bowel symptoms of increased frequency of bowel movements in the morning and generalized fatigue. These symptoms were not speculated to be induced by the FMs placement.

DISCUSSION:
Discussion: EUS-guided placement of FMs for prostate radiation treatment is an achievable alternative to transperineal or transrectal US approaches. Larger studies can contribute to additional outcome data.
2125 Overcoming the Challenge of Full Thickness Resection of Gastric Lesions Using Colonic Full Thickness Resection Device (FTRD): Novel Technique
Authors: Fahmawi Yazan , Kumar Manoj , Mizrahi Meir 
Published: October 2019

INTRODUCTION:
Colonic FTRD (over the scope full thickness resection device) is safe, feasible and approved for colorectal lesions. However, it’s role for upper gastrointestinal (UGI) lesions resection need to be further studied. Colonic FTRD system’s cap diameter is 21 mm which makes it very challenging to insert through the mouth for UGI lesions. We present a case of endoscopic full thickness resection (eFTR) of stomach lesion using colonic FTRD using a novel technique for upper esophagus dilation to assist in the insertion of colonic FTRD through the mouth.

CASE DESCRIPTION/METHODS:
Case Presentation A 49-year-old female was referred to us for endoscopic resection of submucosal lesion suspected for gastric stromal tumor (GIST) prior to bariatric gastric bypass surgery. EGD revealed the lesion in the gastric body. Endoscopic ultrasound (EUS) confirmed it as well demarcated hypoechoic lesion measuring 0.8 cm × 0.8 cm arising from the intersection of submucosal layer and muscularis layer without adjacent lymphadenopathy. FTRD under general anesthesia was planned. eFTR technique: To assist the insertion of colonic FTRD, upper esophagus was dilated with savory dilator size 51 French for 1 minute, then with 55 French for 1 minute and then with 60 French for 5 minutes. Pediatric colonoscope installed with FTRD was gently advanced into the stomach lumen. Circumferential marking of the lesion was done using FTRD marking probe. Favorable positioning was achieved. FTRD grasper was used to grasp and mobilize the tissue into the cap. Clip was applied and snare was hooked to high frequency generator performing high frequency snare resection. Endoscope was removed along with resection specimen. Histopathology revealed fibrotic nodule with complete resection (R0). Endoscopy at 3-month revealed no recurrence.

DISCUSSION:
UGI FTRD is not yet approved in the US. Our case illustrates that colonic FTRD can be used for UGI lesion. Our novel technique of serial esophageal dilation before insertion of larger size FTRD is unique. Similar technique can be used for insertion of future UGI FTRD system as well as its cap diameter is still larger at 19.5 mm which can still be challenging in patients with small upper GI caliber. Since muscularis propria was missing in resected tissue, it opens up a question if device is only capable of eFTR in lower GI tract (thin GI wall as compared to upper GI wall) or if it can achieve similar results with respect to true “full thickness resection” as eFTR in lower GI tract.
2132 Perivesicular Abscess Drainage With Axios Stent
Authors: Mohamed Abdalla , Cavanagh Yana , Estifan Elias , Grossman Matthew 
Published: October 2019

INTRODUCTION:
Pelvic abscesses can occur as sequelae of surgery and are associated with significant morbidity and mortality. The treatment of choice for these abscesses is immediate initiation of broad-spectrum antibiotics and drainage of the collection. We propose that lumen-apposing self-expanding metal stents (LAMS) are a safe treatment option for drainage of pelvic abscesses. LAMS were originally designed for transmural pancreatic fluid collection drainage however have been successfully used for drainage of various extra-luminal fluid collections.

CASE DESCRIPTION/METHODS:
The patient is an obese 34-year-old female with a PMHx of IDDM, and HTN who had recently underwent ex-lap for a large non-malignant pelvic mass. On POD #5, the patient developed a fever and repeat CT revealed a multiloculated pelvic abscess measuring 5.8 × 4.2 cm. IR was unable to drain the collection in this location between bladder and rectum. Rectal EUS was performed and revealed a septated fluid collection viewed best using 7.5 mHz ultrasound at 10 cm from the anal verge. A 2 cm margin was observed between the abscess and the urinary bladder. A 2 mm margin was seen between the rectal wall and the abscess wall. A 19-gauge non-core needle was used to access the fluid collection which appeared purulent. A 15 mm AXIOS stent was then deployed using the same technique employed with pseudocyst drainage. Drainage was successful. 9 days after placement, the stent was removed using a cold snare. No bleeding resulted from stent pull. The defect was then clipped closed with a 15 mm over the scope clip. The patient tolerated the procedure well, experienced complete resolution of the abscess.

DISCUSSION:
Manvar et al suggest that EUS-guided LAMS drainage of pelvic abscesses is more efficacious and has a more favorable safety profile when compared to EUS-guided drainage with catheters and plastic stents. It is an efficient and safe alternative for the management of intra-abdominal and pelvic collections. This case demonstrated the novel use of a lumen-apposing self-expanding metal stent for peri-rectal abscess drainage. Although more evidence is needed for its off-label use, we conclude that it should be strongly considered as a viable treatment option if not the initial treatment modality for collections located in the pelvis.
2136 The Migrating and Perforating Biliary Stent
Authors: Bui Rosa , Sohail Muhammad Adnan , Ashley Christopher 
Published: October 2019

INTRODUCTION:
Although there are high success rates with biliary endoprostheses, there is also accumulating evidence of short and long term complications including: sepsis, migration, perforation, fistula formation and bowel obstruction. This case report presents successful nonsurgical intervention of a rare but grave complication following biliary stent placement.

CASE DESCRIPTION/METHODS:
A 78 year old male with choledocholithiasis underwent an ERCP with incomplete stone removal, necessitating a 10Fr x 5 cm double-pigtail stent. Repeat ERCP at 6 weeks and an abdominal x-ray suggested distal migration of the stent. Despite multiple laxatives, a followup CT scan confirmed stent retention localized to the IC valve. Although he remained asymptomatic, colonoscopy was pursued and unexpectedly revealed one end of the stent penetrating terminal ileum mucosa, with the other end transecting the serosal surface and perforating through the cecum. The stent was removed with a snare and hemostatic clips were placed to close the defect. At 6 months, he continues to do well without any complications.

DISCUSSION:
Stent migration occurs in up to 10% of cases, with less than 1% risk of perforation. Short stents tend to travel proximally while longer stents tend to travel distally causing abdominal pain or bowel obstruction. Stent length (>7 cm), benign strictures, sphincter of Oddi dysfunction, post-sphincterotomy and papillary stenosis have all been associated with higher rates of distal migration. Most stents will pass uneventfully into excreta. Rarely, bowel perforation can occur. The duodenum is the most reported site of perforation due to its fixed setting. However, there have been close to a dozen cases of colonic perforation. Both stent design and patient’s anatomy can be obvious risk factors. Straight plastic stents have been associated with higher risk as compared to metal or pigtail stents. Anatomic aberrancies such as abdominal hernias, extensive adhesions and colonic diverticulae are associated with higher risk. Our case highlights bizarre stent migration/perforation with a theoretically lower risk stent, in an asymptomatic patient without known risk factors. Despite this precarious scenario, endoscopic intervention without surgery was sufficient. The collection of case reports in the literature, including our own, suggests the need for guidelines outlining appropriate measures (e.g. followup intervals for repeat imaging) and guidelines outlining management of biliary endoprostheses complications.
2140 Management of Recurrent Sigmoid Volvulus Using Dual Endoscopic Modalities of Sigmoidopexy and Percutaneous Colostomy Placement
Authors: Kantrowitz Michael , Grunwald Matthew , Tsirlin Yuriy , Adler Harry , Rhee Rebecca , Khodorskiy Dmitriy O. 
Published: October 2019

INTRODUCTION:
Sigmoid volvulus (SV) occurs when the colon twists about its mesentery which can compromise vascular perfusion leading to ischemia. Mortality rate (MR) is up to 60%, requiring emergent endoscopic (ES) detorsion via flexible sigmoidoscopy (FS) with placement of a rectal tube. Recurrence is high, ultimately requiring surgical management. The mean age of presentation is 70 with high likelihood of multiple comorbidities, resulting in high surgical risk. We present a case of ES therapy of recurrent SV.

CASE DESCRIPTION/METHODS:
88-year-old man with colon cancer status post left hemicolectomy (LH), coronary artery disease on antiplatelet agents, atrial fibrillation on anticoagulation, congestive heart failure, and chronic pulmonary disease, presented with abdominal pain, distention and obstipation for two days. The patient had a history of three episodes of SV requiring ES detorsion since LH. Abdominal x-ray revealed a markedly dilated sigmoid colon. Emergent FS was performed with insertion of a 36 French (Fr) catheter resulting in decompression. Computed tomography (CT) was unrevealing for other pathology. Colonoscopy showed a severely redundant, tortuous and dilated colon without other abnormalities. Subsequently, ES sigmoidopexy was performed under fluoroscopy to minimize looping and confirm SV detorsion. Six T-fasteners (TF) were placed cephalocaudally, 5-10 cm apart, with the first TF upstream to proximal region of twisting and the sixth TF downstream to distal region of twisting. A 16 Fr percutaneous endoscopic colostomy (PEC) tube was then inserted as a decompression valve. The tube was affixed to the abdominal wall with two additional TFs inserted adjacent to the third TF to create a triangle within the region of previously dilated lumen. The eight TFs and PEC tube were tightened to abdominal wall, and the tube was connected to a Foley drainage bag. Follow up CT scan confirmed resolution of SV. The patient improved clinically and was discharged home after having formed bowel movements.

DISCUSSION:
Due to high MR, a high index of suspicion for SV is necessary in elderly patients presenting with abdominal distention. Although several case series exist describing ES sigmoidopexy and laparoscopically-assisted PEC tube insertion, to our knowledge this is the only described case of definitive ES therapy using both surgical and ES techniques. While additional cases are required to assess safety and efficacy, this technique may be an addition to the ES armamentarium in managing SV.
2145 Use of Sypbite Forceps to Successfully Remove a Proximally Migrated Biliary Stent: An Effective Alternative
Authors: Naseer Maliha , Mudireddy Prashant 
Published: October 2019

INTRODUCTION:
Biliary stents are essential to therapeutic endoscopy. Although being useful in most cases, several complications are reported in literature. One of them is stent migration. We describe the retrieval of a proximally migrated biliary stent into left hepatic duct complicated by a liver abscess using a digital cholangioscope.

CASE DESCRIPTION/METHODS:
An 83-yrs-old male presented with abdominal pain for 3 days. Denied nausea, vomiting, fever or chills. Patient’s history was significant for pancreatic adenocarcinoma with common bile duct (CBD) stricture diagnosed 1 month prior to this presentation. He underwent ERCP with placement of a 10 F × 9 cm straight plastic stent in the CBD. Post ERCP he did well and was discharged home. A CT scan this admission showed proximal migration of the biliary stent into the left intrahepatic duct along with a fluid-gas collection in the left lobe of the liver. Labs showed leukocytosis, elevated bilirubin and liver enzymes. Patient underwent ERCP for retrieval of the migrated biliary stent. A biliary wire was successfully passed into the left intrahepatic duct. The biliary tree was then swept with three different sizes balloons, but the CBD stent did not move much and remained in the mid duct extending into the LHD. Decision was made to explore the CBD by spyglass. The SpyScope was advanced to the bifurcation. Biliary sludge was found in the entire main bile duct, occluding the stent. Using a spybite forceps the distal end of the stent in the mid duct was grasped and pulled along with the spyscope to the distal most part of the CBD. Major papilla was than dilated and CBD stent was removed using snare. Cholangiography confirmed brisk flow of contrast in entire biliary system. One 10 Fr by 7 cm double pigtail plastic stent was placed 7 cm into the common bile duct to prevent migration.

DISCUSSION:
Proximal migration of biliary stent in an infrequent occurrence with the reported incidence of 4.9%. Several endoscopic techniques have been described with success rate of 80%. Conventional techniques to retrieve migrated biliary stents includes grasping of the stent with rat-tooth forceps, traction retrieval, wire-guided retrieval basket, and snare. Use of SpyGlass cholangioscopy has been reported rarely for the removal of proximally migrated stent. SpyGlass is an effective way of visualization of the migrated stent and removal at the same time which can be used when conventional techniques fail.
2147 Adenomatous Polyp of the Biliojejunal Anastomosis and Bile Duct in a Familial Adenomatous Polyposis (FAP) Patient: A Multidisciplinary Approach to a Clinical Dilemma
Authors: Shah Ravi , Mehta Neal , Li Feng , Jang Sunguk , Yoon Ji Yoon , Mankaney Gautam , Kalady Matthew F. , Church James M. , Burke Carol A. , Walsh R. Matthew , Bhatt Amit 
Published: October 2019

INTRODUCTION:
Duodenal cancer is the second most common malignancy in FAP patients, and advanced polyposis often requires duodenal resection. Post-duodenectomy FAP patients are at risk of developing polyps in the post-anastomotic jejunum. We present a challenging case of a post-duodenectomy FAP patient who developed adenomatous polyp at the biliojejunal anastomosis and bile duct.

CASE DESCRIPTION/METHODS:
A 36 year-old female with FAP, status-post proctocolectomy, pancreas-sparing duodenectomy for Spiegelman stage IV polyposis was found to have polyposis in the jejunum on surveillance capsule endoscopy. Push-enteroscopy revealed polyposis in the jejunum with a 15 mm polyp involving the biliojejunal anastomosis (Image 1). Given that this polyp was non-lifting, it was removed with hybrid endoscopic submucosal dissection (ESD) (Image 2). After polyp removal, there was suspicion the polyp extended into the distal common bile duct (CBD) which was confirmed with biopsies revealing low-grade dysplastic adenoma. After a multidisciplinary discussion, cholangioscopy with Habib EndoHPB radiofrequency ablation (RFA) (Boston Scientific, Marlborough, MA, USA) was planned (Image 3). The adenomatous tissue extended from the distal CBD to the proximal common hepatic duct (CHD) which was confirmed by biopsies. Biliary RFA treatment was inadequate evidenced by poor tissue response noted on cholangioscopy and repeat positive biopsies. We theorized that this was due to poor tissue apposition with the thin RFA catheter as there was no stricture. Given the patient’s young age, extent of bile duct involvement, and poor tissue response to RFA, we determined that a completion Whipple surgery would be the best long-term option.

DISCUSSION:
We present a unique case of a post-duodenectomy FAP patient with adenomatous polyp extending from the biliojejunal anastomosis to the proximal hepatic duct. We were able to remove the polyp at the biliojejunal anastomosis with hybrid ESD, but the biliary adenomatous tissue was not adequately treated by biliary RFA. The thin RFA catheter had poor contact on the bile duct wall as there was no stricture. If a balloon RFA biliary catheter existed that could provide better tissue contact with a normal diameter bile duct, maybe this could have been treated endoscopically. This case highlights the importance of multidisciplinary management of complex polyposis in FAP patients.