bluuebunny/crossref_metadata_2025_split huggingface dataset:
1875 Acute Pancreatitis Due to Clipping of the Ampulla With Over-The-Scope Clip as a Complication of Bleeding Duodenal Ulcer Treatment
Authors: Sehmbey Gurbir , Srinivasan Indu , Chuang Keng-Yu 
Published: October 2019

INTRODUCTION:
Over-the-scope clips (OTSC; Ovesco, Tübingen, Germany) are extensively used for management of gastrointestinal (GI) bleeding, stent anchoring, fistulas, and bowel perforations. Its mechanism of action includes mechanical compression and tissue approximation. Removal of OTSC is indicated when complications occur, which include ulceration, luminal obstruction or clip misplacement. ReMOVE system (Ovesco, Tübingen, Germany) is a safe and effective tool designed to remove the clip.

CASE DESCRIPTION/METHODS:
A 56-year-old male presented to our hospital with abdominal pain and rectal bleeding for 4 days. On examination, the patient had epigastric tenderness and rectal exam revealed melanotic stool with bright red streaking. Labs revealed Hgb of 10.4 g/dL. CT abdomen/pelvis revealed active bleeding in the 2nd and 3rd portion of the duodenum. The patient was started on pantoprazole and red blood cell infusion. EGD revealed a peptic ulcer with an exposed vessel in the 2nd portion of duodenum proximal to the ampulla (Figure 1). Hemostasis was achieved using epinephrine injection and placement of an Ovesco OTSC. Patients hemoglobin stabilized however he continued to experience excruciating abdominal pain. Serum lipase was checked and was elevated to 17,925 U/L. A repeat EGD showed OTSC deployed over the ampulla (Figure 2) and attempts to break the clip using a needle knife and APC were unsuccessful. Two days later, using the bipolar direct current (DC) cutter (remOVE system, Ovesco, Tübingen, Germany) (Figure 3) the clip was removed following which bile was seen to be draining freely. Repeat EGD 1 month later showed normal duodenum with healed ampulla and ulcer.

DISCUSSION:
Ovesco OTSC is an innovative clipping system intended for endoscopic treatment of GI bleeding and closure of acute or chronic wall lesions. The OTSC for flexible endoscopy is an elastic device that works by compression and approximation of tissue. The clip is composed of Nitinol, a biocompatible material that can remain in the body as a long-term implant. RemOVE system can be used for endoscopic OTSC clips removal from the GI tract. It includes DC Cutter which is a bipolar instrument that allows fragmentation by localized melting and cutting of OTSC when used with DC Impulse. The DC Cutter’s tip consists of three electrodes that are brought in contact with the thinnest parts of the nitinol clip which is the frame/hinge. The OTSC must be cut at two spots on opposite side of the row of teeth and the clip fragments can be extracted.
1878 Migration of Over-the-Scope Clip (OTSC) Resulting in Intestinal Obstruction
Authors: Khalid Sameen , Satiya Jinendra , Abbass Aamer , Parasher Gulshan , Castresana Daniel 
Published: October 2019

INTRODUCTION:
Iatrogenic perforations are a known and feared complication of diagnostic and therapeutic colonoscopy. Over-the-scope clips (OTSCs) have recently been utilized for management of these perforations. We present the case of a 40-year-old male patient treated with over-the-scope (Ovesco®) clip for an iatrogenic post-polypectomy perforation with subsequent intestinal obstruction occurring as a result of migration of the clip.

CASE DESCRIPTION/METHODS:
A 40-year-old male with familial adenomatous polyposis and total proctocolectomy, ileoanal anastomosis and a J pouch had an ileoscopy performed for polyp surveillance. A 3 cm flat polyp was removed with Eleview® injection lift technique. A hole like defect was noted in the postpolypectomy site that developed into an obvious small 2-3 mm perforation. To repair the defect, a one 14/6 mm type gc over-the-scope clip (Ovesco®) and a 12/6 mm type gc over-the-scope clip (Ovesco®) was successfully placed. Four months later the patient presented to the emergency department with severe anal pain. He felt a hard metallic object in the anal canal. He denied any fevers, chills, nausea, vomiting, or abdominal pain. Rectal tenderness was found on digital rectal examination. A CT abdomen and pelvis showed an object of metallic density at the anal verge with nonobstructive bowel gas pattern. Colonoscopy revealed two over-the-scope clips approximately 2 cm from the anal verge embedded in the mucosa (Figure 1) which were removed. The patient did well post procedure and was discharged home the next day.

DISCUSSION:
The Ovesco® clip (Ovesco, Tübingen, Germany) is a novel endoscopic method to achieve mechanical compression of gastrointestinal tissue with current indications including closure of fistulas, iatrogenic perforations, hemostasis and non-variceal gastrointestinal bleeding. Iatrogenic perforations during colonoscopy have an incidence ranging from 0.1% to 0.3% of cases. These complications carry a high mortality rate and in the past warranted surgical intervention. However, with the advances in therapeutic endoscopy many perforations can be managed effectively with endoclips, OTSCs and/or endosuturing. These new techniques do come with device-specific risks. Fischer et al. reported the first case of OTSC-induced bowel obstruction. Here we present another case of bowel obstruction as a result of OTSC placement for a perforation, treated with surgical intervention. All gastroenterologists should be aware of clinical scenarios in which the Ovesco clip can be used.
1881 Incidental Finding of an Inverted Appendix in an Asymptomatic Patient With No Surgical History
Authors: Evans Nicole S. , Quezada Michael , Ippoliti Andrew , Shaker Anisa 
Published: October 2019

INTRODUCTION:
An inverted appendix is a rare colonoscopic finding that typically occurs in patients who have undergone an inversion-ligation appendectomy or developed an appendiceal intussusception. There are very few cases of patients with an inverted appendix of unknown etiology reported in the literature. We report a case of an inverted appendix that was incidentally found during colonoscopy in an asymptomatic patient without intussusception or previous appendectomy.

CASE DESCRIPTION/METHODS:
A 66-year-old male with a history of essential hypertension, stage IV chronic kidney disease and atrial fibrillation was referred for a colonoscopy for colorectal cancer screening. He denied any abdominal pain, nausea, vomiting, melena, hematochezia, or other active complaints on initial examination. He has no known surgical history and denies family history of colorectal cancer. Colonoscopy was performed and showed a bulbous-appearing mass protruding into the lumen of the cecum. Examination of the lesion under narrow band imaging revealed normal mucosa. The rest of the exam was unremarkable. Several endoscopists reviewed the imaging of the bulbous-appearing caecal mass, and given the location and appearance of this abnormality, a clinical diagnosis of an inverted appendix was made. Further radiological confirmation with contrast imaging was deferred given the patient’s renal failure. The patient was advised to follow up if any new symptoms developed.

DISCUSSION:
Appendiceal inversion is a unique colonoscopic finding which can mimic other more commonly observed polypoid lesions. Over the past years, only a few cases have been reported in the literature, with even fewer cases limited to patients without history of prior appendectomy, known cystic fibrosis or endometriosis, or evidence of intussusception. As such, the diagnostic features and treatment measures may vary among cases. This case should serve as a reminder to endoscopists to remain aware of such unique anatomic variants and to accurately differentiate these from other more concerning lesions.
1891 Esophageal Intramural Pseudodiverticulosis and Concomitant Esophageal Candidiasis
Authors: Morissette Patricia D. , Kirkpatrick Paul , Tetangco Eula Geralyn , Schubert Moonkyung 
Published: October 2019

INTRODUCTION:
This case pertains to a 65 yo AA M who presented with chronic dysphagia. Multiple EGDs were performed and Esophageal Intramural Pseudodiverticulosis (EIP) was noted along with Esophagitis, strictures and esophageal candidiasis. Esophageal Pitting, or EIP, is described as longitudinal rows of multiple small flask-shaped outpouchings protruding from the esophagus (1,4). Although EIP is not particularly prevalent, esophageal candidiasis is found in 50% of these cases (1). Consisely, clinicians should be aware of EIP and it’s strong association with dysphagia, strictures, and esophageal candidiasis, as such, biopsies should be taken on EGD.

CASE DESCRIPTION/METHODS:
65 yo AAM, with significant PMHx of IDDM and GERD, presented with chronic dysphagia (pills and solid food). On presentation, patient denied any other GI or chest complaints. Patient underwent EGD: Numerous pits were seen in the mid esophagus [Figure 1]. Multiple biopsies were taken and pathology demonstrated fragments of esophageal mucosa with acute esophagitis and yeast forms were identified. Patient also had distal esophageal stricture, which was balloon dilated. He was then lost to follow up. Several years later he returned with dysphagia. On Repeat EGD, diffuse esophageal pitting was seen from 25 cm to the EGJ [Figure 2]. Pathology demonstrated acute esophagitis with focal fungal elements [Figure 3]. No malignancy was seen. Patient was started on appropriate antifungal and daily PPI. Repeat EGD was scheduled for 3 months.

DISCUSSION:
EIP, as noted in our patient, although a rare finding, can be seen in patient’s with Dysphagia (1). 80% of symptomatic patients present with intermittent or progressive dysphagia (1,3). Etiology of EIP to date is unclear. Some association has been seen with inflammatory disease of the esophagus (chronic esophagitis or infectious) (1–4). Management focuses on symptomatic relief along with treating the underlying disease (1,3).
1893 Non-Surgical Endoscopic Management of a Sealed Nail Perforation in the Gastric Antrum
Authors: Tien Andy , Dong Elizabeth , Fahmy Marianne 
Published: October 2019

INTRODUCTION:
Foreign body ingestions are most commonly seen in children, elderly adults, and patients with psychiatric conditions. Perforation is a feared complication, often requiring surgical intervention. We present a case of endoscopic removal of a sealed nail perforation with an over-the-scope clip closure in a patient who was a high-risk surgical candidate.

CASE DESCRIPTION/METHODS:
A 48-year-old homeless male with a history of multiple abdominal surgeries due to gunshots and stab wounds complicated by abdominal hernias presented with 1 week of abdominal pain after drinking an open bottle of soda. Vital signs were stable on presentation. Labs were unremarkable. Computed tomography (CT) revealed a needle-like foreign body in the antrum of the stomach that appeared to project beyond the lumen without signs of pneumoperitoneum free perforation or fluid (Figure 1). An upper endoscopy was performed to further characterize the foreign body. Upon entering the stomach, a 2mm round metallic circular object (Figure 2) was visualized along the lesser curvature of the antrum, suggestive of a nail embedded into the gastric antrum. General surgery was consulted given concern for perforation, however, the patient was deemed a high-risk surgical candidate due to hostile abdominal scarring. The decision was made for endoscopic repair of the nail perforation. On repeat endoscopy, the nail was again visualized in the lesser curve of the antrum; rat-tooth forceps were used to remove a 2.8cm rusty nail (Figure 3) which was safely pulled through an overtube. The scope was reinserted with an over-the-scope clip attached, which was then successfully deployed at the site of perforation. Patient tolerated the procedure well with no signs of peritonitis and follow-up CT four days post-procedure showed the clip in place.

DISCUSSION:
Complications such as perforations and abscesses occur in less than 1% of foreign body ingestions. The most common sites of perforation are the ileocecal valve and other points of intestinal angulations. There are limited cases in the literature of endoscopic intervention in a sealed nail perforation in the stomach in an adult. We found that an over-the-scope clip was effective in sealing a small perforation without evidence of peritonitis on follow-up examinations. Coordination with the surgical service is important in endoscopic repair of perforations. Overall, endoscopic removal of a sealed nail perforation is a viable option for high-risk patients.
1896 Jejunal Migration of Double Pigtail Stent Successfully Removed by Enteroscopy
Authors: Yang Tsujung , Ghimire Subash , Avetisova Mariam , Shah Harshil , Lincoln Matthew J. , Kirshan Ravi Shri Jai 
Published: October 2019

INTRODUCTION:
Walled-off pancreatic necrosis, pseudocyst, and intra-abdominal abscess are common complications after pancreatectomy. Based on the location, the endoscopic drainage can be performed with placement of double pigtail stents. However, the stent itself can cause distal migration months to years later, and it can lead to viscera perforation if not removed in a timely fashion.

CASE DESCRIPTION/METHODS:
We present a case of a 63-year-old woman with history of pancreatic adenocarcinoma status post distal pancreatectomy, splenectomy and partial gastrectomy. Post-surgery, she developed peri-pancreatic fluids collection posterior to the stomach. She underwent cyst duodenostomy, cyst gastrostomy, serial necrosectomies, and sequential placement of AXIOS LAMS (lumen apposing metal stents) and double pigtail plastic stent. LAMS were removed serially after the drainage but double pigtail stent was left behind. A year and half later, she presented to our hospital with left upper abdominal pain for four days. The pain was sharp, stabbing, radiated to left flank, and worsened with deep inspiration and body movements. The review of systems was not significant. She was afebrile and vitals were stable. Physical exam was only significant for moderate tenderness in left upper quadrant and left flank region. Labs showed leukocytosis, thrombocytosis, but normal kidney and liver functions. CT abdomen and pelvis with contrast showed distally migrated double pigtail stent in the mid-jejunum. Enteroscopy using the colonoscope was introduced into the mid-jejunum. A foreign body consistent with the double pigtail stent was found. It was removed with rat-toothed forceps. No perforation was evident post procedure. The abdominal pain resolved completely several hours after the procedure.

DISCUSSION:
Distal stent migration is a possible remote complication if the double pigtail stent remained after complete drainage of intra-abdominal abscesses or pseudocysts. Endoscopic removal is a safe and effective procedure provided that there is no bowel perforation.
1900 Crushing the Star: Esophageal Foreign Body Extraction Using Dormia Basket
Authors: Kilakkathi Sindhu , Shah Rushikesh , Mulki Ramzi , Qayed Emad 
Published: October 2019

INTRODUCTION:
Sharp objects impacted in the esophagus require prompt endoscopic removal. Removal of sharp foreign bodies can be technically challenging and care should be taken to avoid inducing esophageal trauma during retrieval.

CASE DESCRIPTION/METHODS:
A 69-year-old female presented with sudden onset dysphagia and sharp chest pain for 1 day. While eating cake one day prior to arrival, she reported sudden, sharp, central chest pain followed by a sensation of food being stuck in her esophagus. Her physical examination was unremarkable with no abdominal tenderness. Her laboratory tests revealed normal complete blood count and chemistry. Chest x-ray revealed no acute abnormality. Upper endoscopy showed a sharp star-shaped foreign body (FB) approximately 2 cm in diameter (Figure 1). The FB was lodged in the distal esophagus, causing mucosal trauma. Due to the large size of the FB, insertion of an overtube was not considered to facilitate removal. An attempt was first made to extract the FB with rat-tooth forceps, but it could not be retrieved through the upper esophageal sphincter. Mucosal trauma was seen in the mid and proximal esophagus following this attempt. The FB was then advanced to the gastric antrum using a Roth net. Attempts to break the FB using argon plasma coagulation (APC) and a snare were unsuccessful due to the rigid nature of the FB. Subsequently, a 2T dual channel therapeutic gastroscope was inserted, and a Dormia stone retrieval basket was used to grasp the foreign body. Using the crushing power of the basket, the FB was successfully crushed and pulled inside the large therapeutic channel of the scope. The scope was withdrawn without additional mucosal trauma. The FB consisted of a star-shaped cake decoration with sharp edges (Figure 2). Following the procedure, the patient reported immediate improvement in her chest pain.

DISCUSSION:
This is a unique case wherein after the failure of conventional foreign body extraction devices, a Dormia stone retrieval basket was used to crush the object within the stomach allowing for safe retrieval. Gastroenterologists should consider this approach when retrieving irregularly-shaped, sharp, but pliable FBs. For the general public, care should be taken when eating food with non-edible decorations and toppers to avoid inadvertently swallowing or aspirating these objects.
1901 PEG Tube Induced Choledo-Duodenal Fistula: When to Expect the Unexpected
Authors: Jakkidi Manisha , Edirisuriya Cynthia , Elfant Adam , Cooper Robert , Chaaya Adib 
Published: October 2019

INTRODUCTION:
PEG tube has become the modality of choice for providing access for long term enteral nutrition. Despite a good safety record, complications due to PEG dislodgment do occur. We present a case of PEG tube causing Choledo-duodenal fistula, presenting with Ascending Cholangitis. To the best of our knowledge, this unusual complication of PEG tube hasn't been described before.

CASE DESCRIPTION/METHODS:
38 y.o.male with anoxic brain injury, PEG tube placed 6 months ago, presented for evaluation of Jaundice. Vitals were BP 145/108 | Pulse 135 | Temp 101.5 °F. On exam, patient had jaundice, abdomen was soft, Non tender, PEG tube was in the LUQ and Murphy’s sign was negative. Labs showed WBC 12 10X3 U/L, AST 46 U/L, ALT 131 U/L, TB 2.2 mg/dL, DB 1.1 mg/dL. CT abdomen and Pelvis revealed intrahepatic, extrahepatic and CBD dilatation to 1.2 cm, normal Pancreas. PEG tube with fluid-filled balloon was at the level of the pylorus or proximal duodenum. Small and large bowel were nondilated. The diagnosis of ascending cholangitis was made and ERCP was performed. ERCP showed the PEG tube balloon in the duodenum. It was repositioned into the stomach and the scope was advanced to the 2nd portion of the duodenum. There was a large white base ulcer at the duodenal sweep extending into the 2nd portion of the duodenum. Occlusion cholangiogram showed extravasation of the contrast from the distal CBD into the duodenal ulcer. There was a fistulous tract between the CBD and the ulcer. Sphincterotomy was made and a biliary stent was placed to heal the fistula. Biospy of the ulcer showed small intestinal mucosa with ulceration, fibrinoid exudates and no malignancy. Repeat ERCP 8 weeks later for stent removal, showed a chronic entero-biliary fistula.

DISCUSSION:
Our case is unique in that, this is the first CD fistula described in the literature as a complication of PEG tube presenting with ascending cholangitis. We hypothesize that the inflated balloon migrated into the duodenum due to gastric peristalsis and got incarcerated into the duodenum. 90% cases of CD fistula are due to impacted stone in the distal CBD. Other causes are Ampullary carcinoma or Cholangiocarcinoma. Based on our literature review, this is the only reported case of CD Fistula resulting from dislodged PEG tube causing direct pressure necrosis of the duodenal mucosa leading to erosion and fistulation with the distal CBD. Our case brings to light a new and potentially avoidable complication of PEG tubes.
1908 Iatrogenic Severe Rupture of the Spleen Following Colonoscopy
Authors: Enofe Ikponmwosa , Burch Jacob , Yam Julie 
Published: October 2019

INTRODUCTION:
Splenic injury is a rare complication of colonoscopy, with about 100 reported cases worldwide. Identification of splenic injury following colonoscopy is challenging given its non-specific presentation and low incidence. This case report highlights the importance of a high index of suspicion in patients with vague abdominal symptoms post colonoscopy and the need to increase awareness for splenic injury as a possible complication of colonoscopy.

CASE DESCRIPTION/METHODS:
A 72-year-old female presented to the ER with left upper quadrant (LUQ) abdominal pain and weakness 8 hours after a diagnostic colonoscopy. Past medical history included DVT and multiple episodes of PE, for which she was on Coumadin. Coumadin was held prior to colonoscopy. PT and the INR on the day of the procedure were 19.0s and 2.0. Normal findings with no technical difficulties, therapeutic interventions, or biopsies taken during colonoscopy. At discharge, she remained asymptomatic, and Coumadin was resumed. On return, exam revealed normal vital signs and distended abdomen with LUQ tenderness. Labs showed: hgb = 8.1, PT = 15.3s, INR = 1.6, and aPTT = 22.3s. CT revealed peri-splenic fluid collection suspicious for hemorrhage or subcapsular hematoma with free fluid extending into the pelvis. Coumadin was discontinued, and she was managed non-operatively with serial abdominal exams and hemoglobin measurement. Hemoglobin remained stable without requiring blood transfusions. Coumadin was resumed on day 4 and hemoglobin was monitored for another 48 hours, remaining stable at 9.0 g/dl.

DISCUSSION:
Splenic injury is a rare complication of colonoscopy with a reported incidence of 1:6,000 to 1:100,000 colonoscopies performed. Associated symptoms are non-specific with significant variability in timing of onset, posing a diagnostic dilemma for clinicians. Most patients with splenic injury present within 24 hours post procedure. However, some may present after 10–14 days. LUQ abdominal pain is the most common symptom, although in some cases, patients may be asymptomatic. Hypotension, anemia, and elevated white blood cell count may be present as well. Anti-coagulants and anti-platelets have been shown to not increase the risk of splenic injury during colonoscopy. The most accurate test for diagnosing splenic injury is abdominal CT, with a 98 % specificity and sensitivity. Splenic hematoma represents a rare complication of colonoscopy and should be included in the differential for a patient complaining of abdominal pain following the procedure.