INTRODUCTION: Hiatal hernia describes superior herniation of abdominal contents through the diaphragm. This type of herniation occurs when the esophageal hiatus weakens and the positively pressurized abdominal cavity forces contents into the negatively pressurized thoracic cavity. Risk factors include conditions that either increase intra-abdominal pressure (e.g., obesity) or weaken the hiatus and associated structures (e.g., fibromuscular degeneration associated with normal aging). Multiple types and classifications of hiatal hernias encumber assessments of disease prevalence; however, hiatal hernias are broadly classified as either sliding or paraesophageal. While many sliding hernias are asymptomatic, patients may experience reflux-like symptoms due to weakening of the lower esophageal sphincter. Paraesophageal hernias are more serious and can lead to volvulus, bleeding, and respiratory compromise. Surgical repair of the hernia is indicated in symptomatic patients refractory to conservative management and to manage complications; however, surgical intervention is a risk factor for more serious complications such as stenosis and perforation. CASE DESCRIPTION/METHODS: Here we present a case of a 71-year-old female with reflux symptoms diagnosed with a 3 cm hiatal hernia on esaphagogastroduodenoscopy (EGD). After four osteopathic manipulative treatments (OMT), follow-up EGD showed no evidence of hernia or gastritis and the patient reported complete relief of symptoms. DISCUSSION: To our knowledge, this is the first case confirmed by EGD to show a complete reduction of a 3 cm hiatal hernia with OMT being the sole treatment modality. This case demonstrates that hiatal hernias can be managed using OMT, without the use of medications or the need for surgical intervention.
Purpose: Inflammatory fibroid polyp is an uncommon benign polypoid lesion of the gastrointestinal tract. Inflammatory fibroid polyp is more commonly found in the stomach or small intestine, and rarely in the colon. We present a rare case of an 85 year old female (Jehovah's Witness), presenting with iron deficiency anemia caused by a benign fibroid polyp in the colon. Methods: An 85 year old Hispanic female with a past medical history of HTN, vaginal hysterectomy and family history of colon cancer, was referred to our hospital (a center for bloodless surgery), after being found to have a large colonic polyp in ascending colon and iron deficiency anemia. Her Hg was 10.1, HCT 31.5, MCV 78.2, and her stool for occult blood was positive. On colonoscopy, diverticulosis was seen from descending to sigmoid colon and in the ascending colon a large pedunculated polyp with a very thick stalk was found. At the stalk site 6 cc epinephrine, 1 in 10,000 was injected and the polyp was removed using snare polypectomy. Pathology reported the mass as an inflammatory fibroid polyp with multiple erosions measuring 4 × 3 × 3 cm in size. An EGD showed mild hiatal hernia, gastric erosions and mild duodenitis. Patient was never given any iron supplements or erythropoietin injections for the anemia. Follow up labs after 10 months demonstrated normal levels of Hb of 14.6 and Hct 41.7. Thus this patient had an iron deficiency anemia secondary to blood loss from the fibroid polyp which had multiple areas of erosions on its surface, and the anemia resolved on removal of the polyp. Conclusion: Inflammatory fibroid polyp is histologically characterized by a mixture of proliferating fibroblasts and small blood vessels, accompanying a marked eosinophilic infiltrate. The lesion largely affects adults and is more common in the antrum of the stomach, but has occasionally been reported in the small bowel and colon. Although it is generally believed to represent a reactive, nonneoplastic condition, their histogenesis remains unclear. The treatment is surgical excision of the polyp, or colonoscopic resection when it is possible.
Background:The internet has increasingly become an important source of healthcare information. More than 40% of patients say that information found via social media affects the way they deal with their health. Ninety percent of respondents from 18 to 24 years of age said they would trust medical inf
Purpose: Covered self expandable metallic stents (SEMS) have traditionally been used for the treatment of malignant esophageal obstruction; however, recently they have been employed in the treatment of esophageal fistulas. Partially covered SEMS have been shown to be safe and effective and offer the benefit of decreased migration. However, safe removal is difficult due to tissue hyperplasia at the uncovered ends of the stent leading to its embedment into the esophageal wall. We report a case demonstrating successful removal of a partially covered SEMS by pressure necrosis created from placing a fully covered polyflex stent via a “stent in stent” method. A 64-year-old male was referred to our service after development of an esophageal perforation resulting in pneumonia and pleural effusion secondary to a TEE performed during cardioversion for paroxysmal atrial fibrillation. This arrhythmia occurred after the patient had a gastric sleeve procedure for morbid obesity. The patient had a partially covered SEMS placed with the proximal end above the gastroesophageal junction at 39cm from the incisors. The partially covered stent was initially chosen to help create a tissue seal at both ends of the stent to promote healing and to prevent migration. Tissue overgrowth was seen at the proximal end of the stent, but no tissue hyperplasia was seen at the distal end. The distal end of the stent extended down into the proximal gastric body, and the area of the perforation still appeared to be well covered. A 12 cm long fully covered polyflex stent with a central diameter of 18mm flaring out to 23mm at the ends was then successfully deployed under fluoroscopic guidance inside of the previously placed stent with the proximal end overlapping the proximal end of the previously placed stent by 3cm. We then confirmed endoscopically that the polyflex stent was completely covering the area of tissue overgrowth at the proximal end of the stent. Three weeks later, the patient went for repeat EGD, and the polyflex stent was successfully removed with alligator forceps revealing that nearly all of the tissue overgrowth had resolved at the proximal end of the stent from prior exam due to effective pressure necrosis. We initially were unable to remove the partially covered stent by gripping the proximal end with the alligator forceps, and we eventually had to grip the distal end and employ an eversion technique under fluoroscopic guidance with gentle traction to successfully remove the stent. The stent-in-stent technique is safe and effective for the removal of partially covered SEMS that are embedded into the esophageal wall. We recommend further larger prospective trials to analyze this method for the removal of SEMS.
Introduction Inflammatory bowel disease (IBD) is increasingly common among patients with other comorbid chronic conditions, particularly diabetes mellitus (DM). Yet, studies that explored the impact of comorbid diabetes on the outcomes of IBD are scanty. Therefore, this study aims to examine the outcomes of inflammatory bowel disease among hospitalized patients with diabetes mellitus. Methods Using the Nationwide Inpatient Sampling (NIS) database from 2016 to 2018, we identified patients' records with a diagnosis of IBD using the International Classification of Diseases, Tenth Revision codes (ICD-10). The overall study population was further stratified by diabetes mellitus status. We matched patients with IBD and diabetes mellitus (IBD DM) with IBD cohorts using a greedy propensity score matching (PSM) ratio of 1:1 and compared in-hospital outcomes between the two cohorts. Conditional logistic regression was performed to estimate the odds of outcomes. Results Out of the 192,456 hospitalizations for IBD, 34,073 (7.7%) had comorbid IBD DM and 158,383 (92.3%) had no diabetes mellitus (IBD only). Patients with IBD DM are likely to be older. They have higher rates of hypertension, hyperlipidemia, coronary artery disease, obesity, peripheral vascular disease, congestive heart failure, chronic kidney disease, chronic lung disease, chronic liver disease, and stroke than the IBD cohort. After propensity score matching, IBD DM was associated with a lower adverse outcome [odds ratio (OR): 0.96, confidence interval (CI): 0.93 - 0.99, p < 0.01], IBD-related complications (intestinal or rectal fistula, intra-abdominal abscess, toxic colitis, intestinal perforation, intestinal obstruction, toxic megacolon, abscess of the abdomen, and perianal abscess), (OR: 0.76, CI: 0.72 - 0.80, P <0.01), IBD-related surgery (intestinal resections, incision, and excisions of intestine and manipulations of the rectosigmoid, rectal and perianal) (OR: 0.90, CI: 0.85 - 0.95, P <0.01). Furthermore, IBD DM was associated with a higher sepsis complication than the IBD-only cohort (OR: 1.24, CI: 1.19 - 1.30, P <0.01). Conclusion Our results highlight the extent to which diabetes mellitus impacts IBD outcomes and prognosis. Additionally, they emphasize the clinical awareness needed in the management of those with comorbid diseases.
Purpose: Background: The esophageal tonsil of the chicken is a novel, significant element of gut-associated lymphoid tissue (GALT). Its location within the esophagus and its immuno-lymphatic organization fulfills the meaning of the term “tonsil.” The number of tonsillar units is identical with that of the esophageal folds. Each tonsillar unit consists of a crypt lined by lymphoepithelium and surrounded by dense lymphoid tissue, which is organized into T- and B-dependent regions. However the esophageal tonsil is found only in poultry. We present a case of a human patient who was found to have an esophageal tonsil. Case: A 49 year old East Asian man with a 30 pack-year smoking history presented for upper endoscopy after long standing abdominal pain. Physical exam was unremarkable and labs were all within normal limits. The patient was found to have two submucosal nodules 15 cm from the incisors. The patient subsequently underwent endoscopic ultrasound as the lesion looked suspicious for neoplasm. On linear EUS exam, two 1.5 cm hypoechoic submuocsal-based lesions were seen. There was no involvement of muscularis propria. The lesions were then enucleated using a standard snare polypectomy approach to un-roof the lesions and forceps to retrieve the submucosal nodules. Pathology demonstrated squamous mucosa with germinal centers and a narrow central cleft lined by benign squamous epithelium consistent with “tonsilar lymphoid tissue” normally found in poultry. Conclusion: This case demonstrates that the anatomy and phylogeny of various organisms overlap in ways not previously described. The significance of this esophageal tonsilar tissue is that it may participate in B-cell development much like Peyer's patches in human intestine. This is the role of esopagheal tonsils in poultry. Second, tonsilar tissue in the esophagus may participate in the understanding of immune tolerance to undigested antigens, food allergy, and esophageal infections. Thus, we describe the lymphoid accumulation at the junction of the esophagus and oropharynx which has been named named the esophageal tonsil. We recommend further investigation into occurrence of these tonsils and their effect on the immunological function.
Purpose: The current treatment algorithm of HCV involves the use of three medications targeting the viruses' replicative mechanisms. Several alternatives, such as milk thistle, ginseng, and colloidal silver; however, no evidence exists to support that these alternative therapies have any effect on the virus. Furthermore, many clinics outside the U.S. prey upon desperate, infected individuals, promising cures and regenerative therapy for hepatic pathology; one such clinic is Regenerative Cellular Therapy, located in Mexico. Though it is possible that the research being done at these institutions has potential for positive clinical implications, the side effects of unmonitored and unsanctioned treatments can lead to severe consequences. We present a patient who had alternative HCV treatment abroad, that succumbed to overwhelming sepsis and disseminated intravascular coagulation (DIC). A 66-year-old female with a history of leukemia and splenectomy presented to the emergency room with altered mental status, diarrhea, and abdominal pain that began the day prior to admission. On arrival, the patient was severely obtunded and in respiratory distress, and was immediately intubated. A family friend stated she had been injecting herself with an unknown substance she received from a clinic in Mexico for her HCV and cirrhosis. She had no recent sick contacts, and was feeling well until her recent trip from Mexico. On exam, the patient was hypotensive (70/35), tachycardia (122), and saturating well on the ventilator. Her skin was mottled with non-blanching purpuric skin lesions throughout her thorax and extremities. Labs demonstrated a lactic acid of 20, AST/ALT ratio of 162/235, with an alkaline phosphatase of 134 and bilirubin of 1.4. The patient was also in frank renal failure with BUN/Cr ratio of 34/2.9. Her coagulation times had no endpoint detected. A chest x-ray showed no abnormalities. Despite aggressive hemodynamic resuscitative efforts, including vasopressors and antibiotic therapy, the patient expired from overwhelming septic shock and DIC. Her blood cultures eventually grew Streptococcus pneumonia. This case demonstrates the inherent dangers of alternative HCV treatments. This patient self-injected unknown vials of “medications” which may not have been rigorously cleaned or checked for infectious properties. The timing of her presentation and return from Mexico implicate the injectable as a possible source of the Streptococcus pneumonia. That, coupled with her inherent immunocompromised state from her splenectomy, created the perfect storm for septic shock due to encapsulated organisms. We recommend patients should be educated on the dangers of treatments not approved by the FDA for hepatitis C and other chronic illnesses.
Purpose: Prostate cancer is the most commonly diagnosed non-dermatological cancer and second most common cause of cancer death after lung cancer. Prostate specific antigen (PSA) and digital rectal examination (DRE) are complementary screening examinations that, when used in tandem, can increase the overall rate of cancer detection. Performance of rectal exams are trending downward amongst physicians as previous data has shown with 60% of physicians omitting DRE as part of a screening assessment for prostate cancer. Studies have also shown that 22% of elderly men would not undergo prostate cancer screening if it included a DRE. We undertook this study to investigate the usefulness and patient compliance of DRE undertaken by gastroenterologists prior to a colonoscopy. Methods: The study included males over the age of 50 who were scheduled for a colonoscopic examination. Patients with a history of prostate disease, prostate cancer, or a documented PSA were excluded from the study. After informed consent for DRE was obtained, the patients were advanced through the pre-procedure routine. Prior to insertion of the colonoscope, the gastroenterologist performed a DRE including assessment of the prostate. All patients found to have an abnormal prostate examination were referred for a urological consultation. Results: Over a three month period 347 male patients over the age of 50 (average age 59; range 50–80) presented for colonoscopic examination, of which 102 met criteria for inclusion. All 102 patients agreed and consented for the study yielding a 100% compliance rate. Conclusion: Digital rectal exams have been shown to be an important part of a routine physical examination and are a vital screening tool for the assessment of prostate cancer. Without the use of DRE patients are found to have a higher stage at the time of diagnosis and therefore less potentially curable lesions. Although studies have shown that DRE to be the most effective screening test for prostate cancer with a sensitivity of 69%, specificity of 89% and efficiency of 85, it continues to be an underutilized screening tool. With the 100% compliance due to greater comfort for the patient and increased simplicity when performed by gastroenterologists, we propose a more detailed study looking at the initiation of DRE on all patients by gastroenterologist prior to undergoing a colonoscopy.
Purpose: Patients who have large or difficult to remove colorectal lesions are often referred directly to surgery. These polyps can be larger than 2 cm, found at the anal verge, ileo-cecal valve or appendiceal orifice. The application of advanced polypectomy and endoscopic mucosal resection (EMR) techniques is not often considered but may be superior to surgery; especially when recurrence rates at the site of EMR are low. Currently the literature demonstrates recurrence rates range from 10.5% to 20.4%. Methods: We undertook a retrospective review at a tertiary referral center for patients referred for removal of large (>2 cm) polyps over the last 5 years. A difficult polyp was defined as one that was present at the IC valve, appendiceal orifice and ano-rectal junction. 262 patients were identified through our endoscopy database and patients' medical records and follow up was obtained by review of medical records or through phone interview with the patient or referring doctor. 47/ 262 were identified as having had a failed attempt at removal by the referring gastroenterologist. The remaining 215 patient's had difficulty to remove polyps and were successfully treated with a recurrence rate of only 5.4%. Results: The average age was 66 years (42-93 years); 57% were male, of these 47 patients referred to our institution for resection 95% (45/47) were successfully treated whilst 5% (2/47) required subsequent surgical referral. There were no immediate complications and no hospitalizations and only 3 patients required a two-stage procedure to complete. The follow up surveillance colonoscopies were performed 14.7 months (12-18). 13/45 were referred for surgical intervention and resection. The average age was 67 and the range was 55-83; with 5 male, 8 female. The locations of the polyps were 6 in the sigmoid colon, 2 at the appendiceal orifice, and 1 each at the cecum, rectum, splenic flexures, and 2 at hepatic/ flexure. Histology on follow up showed 77% (10/13) with invasive CA and 23% 3/13 with tubular adenomas. Surgery was performed in 61% (8/13) patients; 75% (6/8) of whom had a segmental resection with anastomosis and 25% (2/8) patients had subtotal and total colectomies. Conclusion: In our experience EMR is a simple and safe procedure for removing large and difficult to remove colorectal polyps, and is associated with a very low risk of local recurrence. Surgical intervention plays an important role in those polyps that are deemed unresectable by endoscopic intervention. Based on these findings we recommend that patients with polyps greater than 2 cm with one failed attempt at removal be referred to a tertiary care center for advanced therapeutic endoscopic intervention and subsequent surgical intervention.
