bluuebunny/crossref_metadata_2025_split huggingface dataset:
2150 Successful Endoscopic Closure of a Pyeloduodenal Fistula Using the Over-the-Scope Clip System
Authors: Duh Erica , Clary Meredith , Samarasena Jason , Clayman Ralph , Chang Kenneth J. 
Published: October 2019

INTRODUCTION:
Approximately 100 cases of pyeloduodenal fistula (PDF) have been reported in the literature. PDF most often results from pyelonephritis due to nephrolithiasis, when inflammation extends to the duodenum given its relative immobility and lack of posterior peritoneal covering. Diagnosis of a PDF is usually made with computed tomography (CT) of the abdomen with contrast. The mainstay of therapy for PDF is nephrectomy and primary closure of the duodenum. We are presenting the second documented case of endoscopic closure of a PDF using the over-the-scope clip (OTSC) system and the third case of endoscopically treated PDF. This method provides an alternative to open surgery.

CASE DESCRIPTION/METHODS:
A 62 year old female presented with sharp, severe abdominal pain. She denied back pain, hematuria, fever, and dysuria. She had no significant past medical history and did not take any medications. CT abdomen and pelvis demonstrated a large right-sided staghorn calculus extending into the renal pelvis. The patient underwent percutaneous nephrolithotomy, which was complicated by perforation of the renal pelvis and abdominal compartment syndrome. Subsequently, a proximal ureteral stricture was refractory to stenting and balloon dilation. CT urography demonstrated a PDF (Image 1). After placement of a metallic ureteral stent and nephrostomy tube, a nephrostogram was negative for extravasation, so the patient underwent EGD to evaluate for the resolution of the PDF. During the procedure, iohexol contrast and methylene blue were inserted via nephrostomy tube, and fluoroscopic imaging showed contrast in the right kidney and bladder without extravasation. However, on endoscopy, methylene blue extravasation led to identification of two mucosal defects in the anterior duodenal sweep (Image 2). The larger defect was closed using the helix tissue retractor and OTSC system (12/6 t-type) (Image 3). The smaller defect was closed with 2 hemostasis clips. Follow-up renal scan and CT imaging showed no evidence of contrast extravasation.

DISCUSSION:
The OTSC is an innovative endoscopic technique most often used for hemostasis and for treatment of endoscopic or surgical complications (e.g., fistula, leakage, or perforation). Most reports document successful OTSC use for fistula closure including gastrocutaneous and esophageal fistulas. Our case is, to our knowledge, the second ever documented PDF closure using the OTSC system.
2151 Size Matters: A Case of Recurrent Proximal Esophageal Stenosis Treated With a Biliary Self Expanding Metal Stent (SEMS)
Authors: Viswanathan Sahityan , Dobin Timothy , Hoang Long 
Published: October 2019

INTRODUCTION:
Esophageal stenosis after radiotherapy occurs in up to 15% of patients within 3 months of treatment. Endoscopic dilation remains the standard of care for cervical esophageal stenosis with refractory cases requiring stenting. Proximal stenosis pose a challenge as standard esophageal stents can cause cervicalgia and globus sensation due to their size and expansive force making the a biliary SEMS a better solution.

CASE DESCRIPTION/METHODS:
Patient is a 72 year-old Vietnamese male with pertinent past medical history of stage IV laryngeal cancer status post total laryngectomy, radiotherapy, and tracheostomy presenting with recurrent dysphagia. Patient had previously undergone four endoscopic dilations within the previous month for the same complaint. Upper endoscopy at time of admission revealed a recurrent benign stricture at the level of the upper esophageal sphincter. Given previous failed dilations, severity of stricture, and patient’s refusal for surgical correction or a gastrostomy tube, a biliary SEMS was placed with palliative intent. A fully covered biliary SEMS measuring 10 mm × 60 mm was deployed at the level of the stricture resulting in symptom resolution for 5 months. On recurrence of dysphagia, evaluation revealed distal migration of the SEMS. Retrieval was unsuccessful and the existing SEMS was overlapped with another 10 mm × 60 mm biliary SEMS which resulted in a symptom-free interval of 11 months. Both SEMS were retrieved and exchanged for a fully covered esophageal SEMS (18 mm). Patient had persistent symptoms and endoscopy revealed proximal migration of the esophageal SEMS. The esophageal SEMS was retrieved and a biliary SEMS (10 mm) was again deployed at the level of the stricture which resulted in resolution of symptoms. Patient has since had the stent exchanged every 3-4 months due to stent migration.

DISCUSSION:
Recurrent proximal esophageal stenosis pose a challenge for endoscopists due to their challenging anatomy. Standard esophageal stents currently available in the market start at a diameter of 12 mm making it less ideal for proximal esophageal strictures that cannot tolerate the expansive force of the larger stents. We have demonstrated the success of using a smaller-diameter biliary stent for the relief of dysphagia along with longer symptom-free intervals when compared to dilation and standard esophageal stents. This case demonstrates the need for further research and development of specialized esophageal stents for the treatment of recurrent proximal esophageal stenosis.
2153 Migrated Biliary Stent: When Everything Fails
Authors: Vecchio Eric , Wungjiranirun Manida , Simmons Shannon , Habr Fadlallah 
Published: October 2019

INTRODUCTION:
Migrating stents are a well-known complication of biliary stenting, occurring in 5-7% of patients undergoing ERCP. Numerous endoscopic devices are used to remove stents. However, we describe removal of a proximally migrated biliary stent using a cholangioscopy-guided retrieval basket.

CASE DESCRIPTION/METHODS:
An 86-year-old woman was admitted for septic shock, E. coli bacteremia and cholangitis. Urgent ERCP demonstrated two diverticuli with the major papilla inside one of them. Cholangiogram revealed CBD dilation to 8 mm with few small and large choledocholithiasis. A sphincterotomy and endoscopic dilation of the papilla were performed. However, due to duodenal spasms compromising visualization of the papilla and the associated sepsis, a 10-French by 9 cm plastic stent was placed in the biliary tree and the procedure was aborted. Repeat ERCP four weeks later showed the stent had migrated into the bile duct and was embedded behind the neck of the periampullary diverticulum. Multiple attempts to remove the stent using balloons, baskets, snares and Rat tooth forceps were unsuccessful. A repeat ERCP two weeks later showed the stent still embedded in the bile duct. A Spyglass cholangioscope was introduced into the bile duct and the retrieval basket was used to grasp the distal flap of the stent. Next, both the cholangioscope and stent were successfully withdrawn from the CBD. Finally, the bile duct was swept and remaining stones were removed. Re-inspection of the bile duct with the cholangioscope demonstrated no residual stones or biliary injury.

DISCUSSION:
Biliary stent migration is a relatively uncommon complication of ERCP. Multiple endoscopic tools have been described to retrieve migrated stents. These include retrieval balloons, baskets, and forceps. The newly developed Spyglass retrieval basket allows direct visualization and removal of the targeted object whether it is a stone or stent. This technique is a nice addition to our armamentarium for clearing the biliary tree. It could potentially lead to decreased radiation exposure and probably to a decrease in the number of procedures. The use of this device to remove migrated stents has not been previously reported. The main difficulty in our case was the suboptimal visualization once the basket was tightened around the stent as this blocks the view of the cholangioscope. Further advances are needed in order to develop devices that are able to close further away from the scope camera preserving cholangioscopic view of the biliary lumen.
2159 Endoscopic Management of Isolated Gastric Varices: Hematemesis in Pancreatitis-Induced Splenic Vein Thrombosis
Authors: Peng Frederick B. , Kligman Eugene , Chan Johanna L. 
Published: October 2019

INTRODUCTION:
Brisk upper GI bleeding with acute blood loss anemia requires emergent endoscopic evaluation. Often, lesions are due to peptic ulcer disease or variceal hemorrhage. Here, we present a case of isolated bleeding gastric varices in a patient with splenic vein thrombosis likely due to recurrent episodes of acute pancreatitis.

CASE DESCRIPTION/METHODS:
A 48-year-old man with alcohol abuse, thrombocytopenia, and chronic LUQ abdominal pain presented with four days of hematemesis and melena. He intermittently takes PPI, but reported no NSAID use or history of H. pylori. Previously, two similar episodes associated with severe epigastric pain radiating to his back occurred with heavy drinking. On exam, he is hemodynamically stable with an unremarkable abdominal exam. His admission hemoglobin is 4.9 g/dl and BUN is 26 mg/dl. He is resuscitated with blood products and EGD reveals type 1 isolated gastric varices (IGV) in the fundus with stigmata of recent bleed (Figure 1). Subsequent EUS confirms presence of fundal varices. Hemostasis is achieved with coiling and cyanoacrylate (CYA) glue (Figures 2 and 3). CT A/P shows splenomegaly with chronic splenic vein thrombosis with collateral gastric varices. On discharge, he is counseled on alcohol cessation, as his bleeding gastric varices were attributable to pancreatitis-induced splenic vein thrombosis (PISVT).

DISCUSSION:
PISVT is a sequalae of acute and chronic pancreatitis. The pathophysiology is centered on left-sided portal hypertension with collateral blood flow developing in the splenoportal or gastroepiploic systems. Most patients with subsequent IGV are asymptomatic, but in high-risk symptomatic groups, EUS guided CYA glue injection and intravascular coil embolization is an emerging therapy that has the potential to achieve higher rates of hemostasis and lower rebleeding rates compared to sclerotherapy or balloon-occluded retrograde transvenous obliteration. A recent study demonstrated that out of 100 patients who underwent EUS-guided coil and CYA glue injection, 93 had complete obliteration (on Doppler study) of gastric fundal varices on follow-up EUS examination (Bhat, GIE 2016). Patients who do not achieve hemostasis after CYA injection and coil should be considered for splenic artery embolization or splenectomy, which is currently the gold standard for management of splenic vein thrombosis complicated by variceal hemorrhage. A large comparison trial would be most beneficial to validate this treatment modality compared to existing conventional therapies.
2161 A Rare Case of Pancreatic Lymphoepithelial Cyst
Authors: Kim Grace E. , Ramay Fariha , Richards Stephanie , Darwin Peter 
Published: October 2019

INTRODUCTION:
Pancreatic lymphoepithelial cyst (LEC) is a rare, benign collection of keratinizing squamous epithelial cells encapsulated by lymphoid tissue. Because of its limited data and nonspecific features that can mimic malignant lesions, LECs can lead to unnecessary operations. Here we describe a rare case of pancreatic LEC.

CASE DESCRIPTION/METHODS:
A 62-year-old male with a known pancreatic mass presented with abdominal pain. CT scan showed a 36 × 52 mm mass in the pancreatic head with no pancreatic ductal dilation or retroperitoneal lymphadenopathy (Figure 1), which increased in size compared to previous imaging. Endoscopic ultrasound (EUS) showed a well-defined, avascular 49 × 29 mm heterogenous hypoechoic mass by the pancreatic neck without pancreatic ductal dilation (Figure 2). Subsequent EUS-guided fine needle aspiration (FNA) revealed rare fragments of benign-appearing squamous epithelium in a background of keratin debris, cyst contents, and scattered lymphocytes, consistent with a lymphoepithelial cyst (Figure 3).

DISCUSSION:
Pancreatic LEC is an extremely rare lesion that comprises of only 0.5% of all pancreatic cysts. It occurs in males 50-60 years of age as an incidental finding, albeit patients may present with abdominal pain and nausea. A majority of the LECs are round, anechoic or hypoechoic, exophytic complex cystic lesions with enhancing septa or rim. However, these features can overlap with other pancreatic lesions such as intraductal papillary mucosal neoplasms that have malignant potential, leading to unnecessary surgical intervention. Thus EUS-FNA has become the mainstay for diagnosing pancreatic LECs, which show an outer layer of lymphoid tissue and an inner layer of mature squamous epithelium without atypia. Given the slow growing and benign nature, conservative management and observation is adequate for pancreatic LECs with excellent long-term outcome. With increasing number of imaging ordered by clinicians, it is anticipated that there will be a greater number of incidental pancreatic LECs detected, which in turn can increase the number of unnecessary procedures. EUS-FNA should be utilized more frequently to help distinguish benign pancreatic LECs from premalignant or malignant lesions to avoid surgery. It is important for clinicians to become more familiar with the cytopathological characteristics of pancreatic LECs, and this case highlights the importance of EUS-FNA in accurately diagnosing a rare pancreatic LEC.
2168 Type II Choledochal Cyst With Obstructive Jaundice and Chronic Pancreatitis: A Case Report
Authors: Nallapeta Naren S. , Jamil Sohaib , Rivera Ramon 
Published: October 2019

INTRODUCTION:
Choledochal cysts are a rare congenital cystic dilation of the biliary tract and occur commonly in female infants and young children. Although rare in Western countries, choledochal cysts are more common in East Asian countries with Type II cysts accounting for only 2% of reported cases. We present an interesting case of a Type II choledochal cyst in a patient with chronic pancreatitis.

CASE DESCRIPTION/METHODS:
A 56 year old male presented with abdominal pain associated with nausea and non-bloody emesis. He also had reduced appetite, dark urine, and a 10 pound weight loss over several months. Physical examination revealed scleral icterus and epigastric abdominal tenderness. Laboratory investigations revealed mild leukocytosis (11.1), elevated total bilirubin (8.6), aspartate aminotransferase (77), alanine aminotransferase (128), and alkaline phosphatase (556). A CT with intravenous contrast (Figure 1) demonstrated coarse calcifications within the pancreas, a large cystic lesion within the head of the pancreas with marked pancreatic ductal dilation, atrophy, and intraductal calcifications. Gallbladder distension with sludge and upstream biliary dilatation was also noted. Endosonographic images (Figure 2) revealed an anechoic cystic lesion in the head of the pancreas with compression of the common bile duct (CBD). Fine needle aspiration was performed with aspirated fluid highly suggestive of bile. A cholangiogram confirmed the presence of an intrapancreatic cystic cavity in direct communication with the distal CBD in a diverticular configuration suggestive of a Type II choledochal cyst with narrowing of the adjacent CBD. A pancreatic sphincterotomy followed by pancreas stone lithotripsy and stone extraction was performed. A biliary stent was placed into the CBD. The patient tolerated the procedure well and was scheduled for multidisciplinary discussion pending brush cytology.

DISCUSSION:
Choledochal cysts are congenital anomalies which results in cystic dilation of the biliary tree. Adults are more likely to present with biliary or pancreatic symptoms whereas children present with an abdominal mass and jaundice. Malignancy is associated with Type I and IV cysts while Types II, III, and V cysts have minimal neoplastic risk. Treatment is based on the cyst type. Diverticulectomy of Type II choledochal cyst followed by primary CBD closure at the diverticulum neck is usually sufficient. A multidisciplinary approach may be warranted based on patient clinical status and co-morbidities.
2170 Endoscopic Management of Gastric Outlet Obstruction Due to a Large Gallstone ("Bouveret's Syndrome")
Authors: Ali Saad Emhmed , Benrajab Karim , Tripathi Nishant , Gabr Moamen , Mardini Houssam , Frandah Wesam 
Published: October 2019

INTRODUCTION:
Bouveret's syndrome is referred to a gastric outlet obstruction due to an impacted gallstone in the duodenum following cholecystoduodenal fistula. Surgery is required in certain cases, but the mortality rate is up to 30 %. Endoscopic management has been reported with a low success rate. We demonstrate a successful endoscopic mechanical and electrohydraulic lithotripsy of a large gallstone causing gastric outlet obstruction.

CASE DESCRIPTION/METHODS:
A 88 years old female presented with a three-day history of right upper quadrant abdominal pain (RUQ), nausea, and non-bilious vomiting. Past medical history is significant for hypertension, coronary artery disease, and type 2 diabetes. Vital signs were normal. Pertinent findings included tenderness to palpation in the epigastric and RUQ regions, normal bowel sounds, and a loud succession splash. Labs revealed Hgb 10.2 g/dl, WBC 7k/mm3, platelets 289k/mm3, BUN 13 mg/dl, creatinine 0.6 mg/dl. Plain abdominal X-ray showed round calcified structure in the right mid abdomen (Figure 1). CT scan of the abdomen showed 4 cm × 3.5 cm gallstone causing complete obstruction of the duodenum, cholecystoduodenal fistula, pneumoperitoneum, and distended stomach (Figure 2). Upper endoscopy revealed a large gallstone impacted in the first part of the duodenum, extensive ulceration of the duodenal wall with a small perforation at the site of stone impaction (Figure 3). Mechanical and electrohydraulic lithotripsy was performed, and the stone was fragmented into small pieces in the duodenum. There was spontaneously sealed duodenal perforation with fat and omental plug. The endoscopic lithotripsy was performed without difficulty. The patient was improved, tolerated an oral diet, and discharged home in a stable condition.

DISCUSSION:
Bouveret’s syndrome is a rare cause of gastric outlet obstruction and characterized by impaction of a gallstone within the pylorus or duodenum. It occurs mostly in elderly, female patients with an average age of 70 years. Given that most patients are elderly with multiple comorbidities, they are poor surgical candidates. The endoscopic approach is considering to be a good alternative. As we demonstrated in our case, these patients can be successfully managed endoscopically with lithotripsy despite the low success rate that was reported in the literature. Endoscopic treatment is effective and safer and should be considered as a first line option.
2171 EUS-Guided Transrectal Drainage and Stent Placement for Large Presacral Abscess Secondary to Acute Appendicitis
Authors: Ali Saad Emhmed , Elghezewi Adnan , Gabr Moamen , Mardini Houssam , Frandah Wesam 
Published: October 2019

INTRODUCTION:
A presacral abscess is one of the most difficult abscesses to be drained. It is very challenging to drain it through the transabdominal route due to overlying pelvic structures. We present a patient with sizeable presacral abscess secondary to acute appendicitis that was drained transrectal under an endoscopic-ultrasound (EUS) guidance with stent placement.

CASE DESCRIPTION/METHODS:
A 23-year old male presented with worsening pelvic pain, fever, and chills for four weeks. He denies any change in the bowel movement, dysuria, recent trauma, or bladder or bowel incontinence. Past medical history was unremarkable and had no surgeries. Vital signs were normal except for the temperature of 101.2 F. Abdomen was soft, non-tender, with audible bowel sound. The rectal and genital exam was normal. Labs revealed Hgb 11.2 g/dl, WBC 17.9k/mm3, platelets 545k/mm3, creatinine 0.7 mg/dl, CRP 18.8 mg/dl, negative HIV, and negative urine and blood cultures. CT scan of the abdomen and pelvis revealed large presacral abscess and possibly ruptured acute appendicitis. Magnetic resonance enterography (MRE) showed 9.6 × 2.6 × 6.1 cm presacral abscess with acute ruptured appendicitis (Figure 1). Interventional Radiologist was consulted for drainage, but abscess was not amenable to be drained percutaneously. Despite being on intravenous antibiotics, the patient continued to be spiking febrile and having persistent pelvic pain. So, rectal endoscopic ultrasound (EUS) was performed and showed 5 cm × 3.5 cm abscess in the pre-rectal space (Figure 2). Aspiration was done with the 19-gauge needle using a transrectal approach. A 7Fr x 5 cm double pigtail plastic stent and a 10Fr x 5 cm double pigtail plastic stent were placed into the abscess (Figure 3). Good drainage from the stent was visualized into the rectum. Patient’s symptoms improved. Fluid cultures remained negative, Leukocytosis resolved, and he was discharged in a stable condition. He will follow up with a repeated CT pelvis in 2 weeks to assess for resolution of abscess and interval appendectomy.

DISCUSSION:
The presacral abscess is a complication with difficult management in the course of acute appendicitis. It is challenging to drain with the transabdominal route because of the overlying pelvic structures. EUS-guided transrectal drainage is safer and effective in these cases. The clinician should be aware of this treatment modality and considered as the first-line option.
2172 Importance of Chest and Abdominal Imaging Before Placing a PEG Tube
Authors: Chaudhury Samiran Roy , Oak Rachana , Kumar Kavita , Bernstein Michael 
Published: October 2019

INTRODUCTION:
Percutaneous Endoscopic Gastrostomy (PEG) tube placements are a common procedure these days and are often seen as a safer and cheaper alternative to surgical gastrostomy tube placement with increasing rate of deployment over the years. They are however dependent on several factors including anatomic presentation and availability of resources.

CASE DESCRIPTION/METHODS:
A 75 year old lady with multiple medical conditions who came to hospital from nursing home after she was noted to have failure to thrive and dysphagia. After admission GI was consulted for PEG placement. Initial physical exam during the consult revealed benign abdomen – non tender, non-distended with present bowel sounds without deformities. On imaging however, the chest x-ray (Figure 1) shows the presence of the patient’s stomach and small bowel within the patient’s chest cavity due to a large hiatal hernia, as well as pleural effusion with left lower lobe infiltrate. CT chest (Figures 2 and 3) was done to confirm CXR findings and revealed a large retro-cardiac hernia containing multiple loops of large bowel, small bowl and stomach with segmental left lung subluxation. Patient was treated with antibiotics for aspiration pneumonia; however, patient was deemed to be a poor candidate for PEG placement due to anatomy as well as a poor candidate for hernia repair given advanced age and comorbid medical conditions. Given poor prognosis, goals of care were discussed with patient’s family who opted for a palliative approach and patient was eventually discharged to a hospice care facility.

DISCUSSION:
While PEG placement is becoming a rapidly prevalent procedure, there is no guideline regarding risk stratification of placement with use of imaging. In our experience, imaging should be a main stay of initial investigation alongside history and physical exam given that anatomic variations/changes may not always be apparent on history and physical exam alone.