bluuebunny/crossref_metadata_2025_split huggingface dataset:
2112 Delayed Onset of Inflammatory Bowel Disease During Treatment With Secukinumab
Authors: Nallapeta Naren S. , Picano John D. , Bou-Abdallah Jad 
Published: October 2019

INTRODUCTION:
Secukinumab is an interleukin-17 inhibitor commonly used for treating ankylosing spondylitis (AS). Recent reports described new onset inflammatory bowel disease (IBD) in patients treated with Secukinumab. To our knowledge, this is the first case report to describe a delayed presentation of new onset IBD in a patient 14 months after beginning treatment with Secukinumab.

CASE DESCRIPTION/METHODS:
A 68 year old male presented with 2-3 bloody bowel movements per day, fever and 20 lbs of unintentional weight loss for six weeks. Past history was significant for AS treated with Secukinumab for 14 months after failing therapy with other biologics (Etanercept, Adalimumab and Infliximab). A screening colonoscopy 3 months prior to presentation revealed no evidence of colitis. Labs were notable for an elevated WBC 13.2 and ESR 74, stool testing was negative for Clostridium difficile. A flexible sigmoidoscopy showed erythematous mucosa beginning in the rectum. Multiple deep ulcerations were noted beginning at 30 cm (Figure 1) and biopsies showed a diffuse pattern of brisk chronic active colitis. Secukinumab was discontinued. Methylprednisolone and mesalamine were begun and resulted in significant improvement in his symptoms. The patient presented again with similar symptoms one month later. Repeat flexible sigmoidoscopy showed partial healing. Biopsies demonstrated chronic active colitis consistent with IBD. A repeat flexible sigmoidoscopy performed 6 later showed complete mucosal healing (Figure 2).

DISCUSSION:
We present the first case report of delayed onset IBD in a patient with AS treated with Secukinumab. Previously reports demonstrated a rapid onset of presentation, usually either after first infusion or within a few weeks of treatment (JCC, 2018, 1131-1133). Interestingly, our patient had a routine screening colonoscopy 3 months prior to symptom onset which showed no evidence of IBD. The pathogenesis of new onset IBD in patients treated with Secukinumab is not clear. IL-17A is known to be pro-inflammatory in IBD but certain mouse models demonstrated IL-17A to be protective in T cell mediated colitis, and IL-17A-deficient mice developed rapid weight loss and severe colitis (Nat Immunol. 2009;10:603–9). This case suggests that new onset IBD in patients taking Secukinumab may present many months after initiation of therapy. Clinical suspicion should remain in patients with symptoms suggestive of IBD many months after starting, and even tolerating, Secukinumab.
2119 Acute Post-Operative Drainage With a Lumen-Apposing Metal Stent (LAMS)
Authors: McDonald Nicholas M. , Storm Andrew C. 
Published: October 2019

INTRODUCTION:
Peripancreatic fluid collections may occur following pancreatic resection and are traditionally managed by percutaneous surgical drains. Endoscopic management of these peripancreatic fluid collections is increasingly utilized and there is growing experience in this realm.

CASE DESCRIPTION/METHODS:
A 54-year-old woman with a history of resectable adenocarcinoma of the pancreatic tail (T1a) who received FOLFIRINOX neoadjuvant therapy and was transitioned to Gemcitabine/Abraxane, presented for surgical management. She initially underwent laparoscopic, hand-assisted distal pancreatectomy and splenectomy. She tolerated surgery with no immediate complications. On postoperative day #4, she developed moderate abdominal pain. Computed tomography (CT) demonstrated an irregularly-shaped, hypodense fluid collection measuring 7.5 × 6.5 × 8.3 cm about the pancreatic tail, concerning for pancreatic duct leak. The decision was made to perform endoscopic drainage under endoscopic ultrasound guidance. On postoperative day 6, EUS demonstrated a 7 × 4 cm septated collection in the postoperative bed in the region of the distal pancreas (Figure A). The acute collection had not yet become walled off based on CT and EUS. The common wall between the stomach and cyst was interrogated utilizing color Doppler and an ideal puncture sight was determined. An electrocautery enhanced lumen apposing metal stent (LAMS) was advanced into the cyst and a 10 × 10 mm LAMS was placed with flanges in close approximation to the fluid collection and stomach wall through cystgastrostomy (Figure B). An additional 7 Fr by 4 cm soft double pigtail stent was then placed coaxial to the LAMS to maintain patency. At follow-up, two weeks later, her abdominal symptoms had resolved. Her interval scan demonstrated a significantly decreased pancreatic tail collection and transgastric LAMS. At postoperative day 10, cross sectional imaging demonstrated complete resolution of her fluid collection, and endoscopy was performed with uneventful LAMS removal (Figure C).

DISCUSSION:
This case demonstrates a patient with an acute postoperative peripancreatic fluid collection after distal pancreatectomy which was successfully treated six days postoperatively with transgastric cystgastrostomy using a LAMS. While traditional management in the acute postoperative setting has been percutaneous drain placement, further study is needed to evaluate the safety and efficacy of minimally invasive, endoscopic methods of postoperative drainage.
2120 A Rare Case of Primary Adrenal Leiomyosarcoma Diagnosed via EUS-Guided Fine-Needle Biopsy
Authors: Gajula Prianka , Dacha Sunil 
Published: October 2019

INTRODUCTION:
Leiomyosarcoma is a rare tumor that arises from smooth muscle wall. It is well known to be an aggressive tumor usually found in the uterus or abdominal cavity. However, primary adrenal leiomyosarcoma (PAL) is rarely seen. Here, we present a case of PAL diagnosed by endoscopic ultrasound-guided fine needle biopsy (EUS-FNB).

CASE DESCRIPTION/METHODS:
A 69-year-old female presented with a 3-week history of cramping LUQ abdominal pain and left flank pain. Medical history was remarkable for seasonal allergies and adult Still’s disease at the time of diagnosis. A CT and MRI of the abdomen with renal protocol was performed, which revealed a large, heterogeneous mass in the retroperitoneum and in continuity with the posterior wall of the gastric fundus and measuring 7.3 × 5.1 cm. This mass displaced the adrenal gland medially and the kidney posteriorly. The patient underwent EUS guided biopsy of the mass. On endoscopic examination, there was extrinsic compression in the fundus and posterior wall of the proximal body of the stomach. Endosonographic examination confirmed this compression to be due to a retroperitoneal mass. This measured 71 mm × 48 mm in cross-section. It was heterogeneous in appearance and abutted the posterior wall of the stomach. The mass lesion appeared to originate from and compress over the left adrenal gland. Cytopathologic evaluation was consistent with a spindle cell carcinoma, suggesting a leiomyosarcoma. Immunostains showed the spindle cells positive for SMA, but negative for c-Kit, DOG-1, and S100. Shortly thereafter, a pancreatectomy, splenectomy with left nephrectomy and adrenalectomy were performed concurrently by surgical oncology and urology. Post-surgical course was uncomplicated. Final pathology was suggestive of an 8 cm Leiomyosarcoma of the left adrenal gland with no vascular invasion and margins free of tumor.

DISCUSSION:
Primary adrenal leiomyosarcoma is exceedingly rare. There are only approximately 40 reported cases. Literature review reveals that the majority of these cases were diagnosed after laparoscopic or open surgical resection. There is only one prior reported case of PAL diagnosed by EUS guided tissue sampling. This case demonstrates the well-documented safety and efficacy of EUS-FNB for diagnosing mass lesions when cross-sectional imaging is equivocal and performing biopsies of these lesions. GI tract provides a unique window for performing high-quality imaging by EUS guided examination and simultaneously performing transmural interventions.
2122 Novel Use of EndoRotor® Device to Clear Large Obscuring Clot in Patient With Upper Gastrointestinal Bleed
Authors: Gubatan John , Kwo Paul , Hwang Joo Ha 
Published: October 2019

INTRODUCTION:
Significant clot burden limits visibility and prevents finding intervenable lesions for hemostasis. Endoscopic tools and promotility agents are available to disrupt clots and increase visibility with varying degrees of success. The EndoRotor® device is a non-thermal, automated endoscopic resection system designed to remove benign mucosal tissue throughout the gastrointestinal tract. Here, we present a challenging case where standard endoscopic techniques failed to clear a large obscuring gastric clot and how novel application of the EndoRotor® allowed successful localization of the culprit lesion.

CASE DESCRIPTION/METHODS:
A 79 year old woman with a history of end stage renal disease and liver fibrosis presented with coffee ground emesis and melena. On admission, initial labs were notable for Hgb 9.7, Plts 129, INR 1.1. Patient was treated with IV pantoprazole and octreotide. EGD was notable for nonbleeding esophageal varices and a moderate size blood clot in the lesser curvature and fundus of stomach obscuring visualization and the procedure was terminated. Patient continued to pass melena with Hgb drop to 5.8 requiring 3 units pRBC and metoclopramide was added to her regimen to try to clear the large clot. Repeat EGD revealed an interval increase in size of blood clot. Despite irrigation and suction, area could not be cleared. Use of cold snare or Roth net removal were not feasible due to clot size and use of BioVac® was ineffective. A repeat EGD was performed the following day using the EndoRotor®. The combination of the EndoRotor device’s rotating cold blade and suctioning enabled the large clot to be liquefied. Fibrous tissue intermittently clogged the EndoRotor® suction channel but was easily cleared with flushing. After about 30 minutes, the large obstructing clot was completely cleared revealing a bezoar. The patient was kept NPO and continued on IV metoclopramide for 48 hours to clear the bezoar. An EGD was then repeated which revealed a 5 mm cratered ulcer in the posterior gastric wall with a nonbleeding visible vessel. Bipolar probe was applied successfully for hemostasis.

DISCUSSION:
Our case illustrates the challenges associated with a large clot obscuring visualization. Standard use of promotility agents with supportive care were not successful as the patient continued to intermittently bleed increasing the clot size . Our case is the first reported application of the EndoRotor® to safely to clear large blood clots in upper GI bleeding as an adjunct to our standard therapies.
2126 Endoscopic Ultrasound-Guided Splenic Mass Biopsy. an Accessible Technique for Differential Diagnosis of Lymphoma
Authors: Leon-Jarrin Daniela , Fahmawi Yazan , Kumar Manoj , Mizrahi Meir 
Published: October 2019

INTRODUCTION:
Traditional methods for splenic mass biopsy includesurgical or percutaneous technique, however there is an increased risk of hemorrhage, hematoma or cutaneous infection associated with these techniques. In addition, these techniques do not allow us to evaluate adjacent organs. Endoscopic ultrasound (EUS) provides a novel method for splenic mass biopsy and should be considered for such procedures. Our case highlights technique for a successful and safely done EUS guided splenic mass biopsy.

CASE DESCRIPTION/METHODS:
Case: 68-year-old female with history of non-Hodgkin lymphoma in remission, stage IIIbsquamous cell carcinoma of anus treated with chemoradiation and on surveillance referred to GI after a surveillance CT abdomen/pelvis revealed spleen enlargement with hypodensities. This was followed by PET/CT with increased uptake on anal region, spleen, stomach and supraclavicular node. Endoscopy with EUSwas performed. Biopsies were obtained from stomach and duodenum. EUS imaging showed splenic lesion. Fine Needle Biopsy was performed with 22-gauge needle with a slow pool technique. 4 needle passes were made into the mass. Specimen was sent for pathology and flow cytometry. Patient tolerated procedure without complications. Biopsy report showed evidence of B cell lymphoma on all samples with diagnosis of relapsed B cell Non-Hodgkin lymphoma.

DISCUSSION:
EUS can provide a feasible and safer technique to obtain splenic mass biopsies. This technique utilizes the proximity of gastrointestinal tract and therefore a readily accessible path to obtain splenic biopsies. Endoscopic ultrasound can also provide a safe way to evaluate adjacent organs during the work up of disease extent involvement, all in one minimally invasive procedure,reducing the amount of risks and complications associated with traditional biopsy techniques.
2131 Endoscopic Mucosal Resection of a Proximal Esophageal Pyogenic Granuloma
Authors: Estifan Elias , Patel Varun , Grossman Matthew 
Published: October 2019

INTRODUCTION:
Pyogenic Granuloma (PG), also known as lobular capillary hemangioma, is usually seen as a polypoid red lesion found on the skin or the mucosal surface of the oral cavity. PG of the gastrointestinal tract is rare, in particular involving the esophagus, only 14 cases have been reported in the English literature.

CASE DESCRIPTION/METHODS:
We present an 80-year-old male who underwent endoscopy for evaluation of dysphagia and was found to have a single, red, bilobed 10 mm polyp with adherent white exudate approximately 19 cm from the incisors (Figure 1). Endoscopic ultrasound was performed with a 20 mHz miniprobe which showed the lesion contained to the mucosal layer with no muscularius propria invasion. A decision was made to perform endoscopic mucosal resection (EMR). A mixture of saline and methylene blue was injected into the submucosal plane to raise the lesion with subsequent successful mucosal hot snare resection (Figure 2). The resection defect was then approximated and closed with a hemostatic clip to prevent bleeding. Pathology of the specimen revealed small capillary vessels growing in a lobular architecture with an edematous stroma and a florid inflammatory infiltrate representing a pyogenic granuloma (Figure 3).

DISCUSSION:
EMR allows for an en bloc resection of mucosal lesions with tumor-free margins thereby providing both diagnostic and prognostic information. Comparing EMR with the novel technique of endoscopic submucosal dissection (ESD), the incidence of bleeding and perforation is much lower; making EMR the best and safest resection option for this rare hemangioma. In this case, we demonstrate that EMR is a safe technique in removing a pyogenic granuloma in the esophagus.
2143 A Unique Complication of Gastrostomy Tubes
Authors: Baloch Luqman 
Published: October 2019

INTRODUCTION:
In 1979 the Gauderer-Ponsky technique was developed to allow endoscopic placement of gastrostomy tubes (G-tubes). The procedure allowed fistulation between the stomach and abdominal wall. G-tubes are often placed for enteral feeding in patients who have either an inability or insufficiency of intake by mouth. Complications of G-tubes are often seen but an overwhelmingly majority of them are minor. At times G-tubes lead to soft tissue & skin infections, colocutaneous fistulas, & visceral perforations. These more serious complications can occur up to 11-15%. Smaller complications such as dislodgement or G-tube dysfunction are far more common.

CASE DESCRIPTION/METHODS:
A 49 year-old male with a past medical history of traumatic brain injury with placement of a percutaneous endoscopic gastrostomy tube (G-tube) who presented to the ED after pulling out his G-tube. Unable to place the G-tube back at bedside, interventional radiology reinserted under fluoroscopy. After discharge he presented back to the ED with coffee ground emesis & aspiration. He was noted to have klebsiella pneumonia. Despite being appropriately treated for his pneumonia he continued to have worsening septic shock abdominal distention. CT imaging was positive for large collection of fluid, gas, & contrast filling his peritoneum. Emergent exploratory laparotomy found 6L of peritoneal fluid & a perforated fistulous tract draining into his peritoneal cavity. Meanwhile his abdominal viscera was coated with a white film. Labs & cultures confirmed peritonitis caused by klebsiella, enterococcus, & candida. He received antibiotics and antifungal therapy, required multiple washouts, & surgical correction of the perforation with a wedge gastrectomy.

DISCUSSION:
This patient developed a rare & serious complication after G-tube placement. Dislodging the G-tube in a traumatic fashion caused drainage into his peritoneum. Even though the G-tube was replaced under radiographic guidance he developed a terrible case of peritonitis. The rates of complications are statistically the same in radiographically or endoscopically placed G-tubes. This patient required surgical placement of another G-tube along with and a wedge gastrectomy. This complication of fungal peritonitis & aspiration pneumonia show us that G-tubes are not always benign. Endoscopic, surgical, and radiographic techniques may all have a different approach to ensure good outcomes but a patient’s ability to receive good G-tube care is essential in preventing long term complications.
2144 Gastric Hyperplastic Polyps Are Resistant to Treatment by Endoscopic Submucosal Dissection
Authors: Roy Justin , Loloi Justin , Moyer Matthew , Mathew Abraham 
Published: October 2019

INTRODUCTION:
Hyperplastic gastric polyps represent a subset of gastric polyps that are known to have malignant potential, with 5-19% harboring focal dysplastic changes, suggesting there would be a benefit to resection. Size > 1.0 cm and pedunculated morphology have been shown as clear risk factors for malignant transformation. Current ASGE recommendations state that any hyperplastic polyp > 0.5 cm be resected. Despite these recommendations, it is unclear how successful current endoscopic techniques are in the long-term management of these polyps. In this study, we sought to better understand if endoscopic submucosal dissection (ESD) would be successful in sustained removal of hyperplastic polyps.

CASE DESCRIPTION/METHODS:
We conducted a retrospective review of all patients between 2013 and 2019 who underwent ESD at our institution. Those who underwent ESD for treatment of hyperplastic polyps were included. Both the endoscopy reports and pathology reports were analyzed for ESD procedures looking at documented complications, polyp size, and enbloc removal.

DISCUSSION:
In total, 188 underwent ESD during the time frame studied, and 9 patients met inclusion criteria. In total, 12 ESD procedures were found. On average, each patient underwent 1.6 endoscopies prior to ESD, and 4.9 total for treatment of hyperplastic polyps. When removed by ESD, the average polyp size was 37 mm (range: 15 – 80 mm), and 63.6% were able to be removed enbloc. All polyps were located in the antrum. During ESD, there was intra-procedure bleeding during 83.3% of cases. This was controlled with clips, APC, and overstitching. No patients required hospitalization or emergent surgery. Of the 12 ESD procedures documenting successful polypectomy, 8 had follow up endoscopies within 12 months, with 100% recurrence of hyperplastic polyps. The remaining 4 are awaiting or lost to follow-up. Hyperplastic polyps involving the gastric antrum need removal due to cancer risk and often blood loss. Those resistant to standard resection can be effectively removed by ESD. Although ESD safely and successfully removed polyps, our patient population with follow up suffered a 100% recurrence rate of polyps despite good margins. Thus ESD, while safe, is not successful preventing recurrence. The pathological basis for this recurrence is unclear. We conclude that large gastric polyps recur almost always even after successful removal of by ESD.
2158 Successful Endoscopic Retrograde Cholangiopancreatography in a Patient With Situs Inversus and Choledocholithiasis
Authors: Holmes Ian , Ostroff James W. 
Published: October 2019

INTRODUCTION:
Situs inversus is a congenital condition that causes left-right reversal of all organs. This results in unique challenges for the endoscopist when patients with situs inversus require ERCP. Several methods have been described in the literature to optimize the chances of successful cannulation in these unique patients. We describe the case of a 75 year old woman with situs inversus who developed choledocholithiasis requiring ERCP for stone extraction. We review the clinical features of situs inversus, as well as the methods needed to obtain successful cannulation.

CASE DESCRIPTION/METHODS:
A 75 year old woman with complete situs inversus was transferred to our facility. Eight days prior to this presentation, she developed epigastric pain and emesis. She had new liver test abnormalities with ALT 277, AST 110, alkaline phosphatase 221, and total bilirubin 5.5. A CT scan showed dilation of the common bile duct to 7 mm with a 6 mm stone noted in the distal duct. Upon arrival at our facility, ERCP was performed in the left lateral position. The procedure was notable for distortion of the stomach and duodenal bulb consistent with situs inversus. A precut sphincterotomy was necessary to achieve biliary cannulation. The bile duct was noted to come off the ampulla at 1 o’clock, in mirror image from normal anatomy. A 9 mm stone was identified and removed with a basket.

DISCUSSION:
Situs inversus is an autosomal recessive congenital condition with an incidence rate of approximately 1 in 5,000 to 10,000 live births. There is no evidence that situs inversus contributes to increased gallstone formation. Currently, there are 15 cases of ERCP performed for choledocholithiasis in situs inversus patients described in the literature. Besides the obvious differences in the orientation of the stomach and duodenum, the bile duct is often noted to come off the ampulla at “1 o’clock” instead of the typical “11 o’clock.” A variety of methods have been described to address these anatomical differences, including placing the patient in the prone position, changing the side of the bed that the endoscopist stands on, setting up the ERCP suite in mirror image, and rotating the duodenoscope 180 degrees clockwise in the stomach, and then either rotating an additional 180 degrees in the second portion of the duodenum or using a rotating sphincterotome. Endoscopists should be aware of the various techniques to optimize cannulation in patients with situs inversus to maximize chances of a successful intervention.