Purpose: A 71-year-old female with medical history of CAD, HTN, and chronic anemia presented with longstanding symptomatic microcytic anemia (Hgb 10.2-12; MCV 72-76.7). Esophogastroduodenoscopy in 2008 showed two 1.5cm duodenal polyps. Histology revealed positive congo red staining, suspicious for amyloid deposits. The patient was subsequently evaluated by video capsule endoscopy which showed recent active bleeding in the duodenum and/or proximal jejunum in association with several focal areas of superficial erythema and ulceration. The patient was lost to follow-up and no further work-up was done for systemic amyloidosis via SPEP, UPEP, or bone marrow aspirate. Two years later, the patient was evaluated with a double balloon enteroscope (DBE) for persistent iron deficiency anemia and melenic stools. DBE showed approximately 20 broad based polyps from 5mm to 3cm with normal overlying mucosa. The polyps were friable on biopsy and oozed for some time before hemostasis was achieved. On scope withdrawal, trauma of the friable mucosa was noted at the polyp sites as a result of the scope brushing against the polypoid tissue. Pathology was significant for extensive nodular AL amyloid deposition in the submucosa and encasing submucosal blood vessels. Methods: Nodular or globular amyloid of the GI tract is rare and there have only been a few case reports to our knowledge. More common is linear amyloid deposition which usually presents with weight loss due to motility disturbances resulting from autonomic neuropathy. Results: In contrast, our patient has globular AL amyloid deposition which more commonly presents as obstruction or pseudo-obstruction. We postulate that this patient's anemia was secondary to occult chronic hemorrhage from submucosal blood vessel involvement resulting in mucosal fragility. In severe amyloidosis, such vascular compromise can lead to infarction and/or perforation of the bowel. Conclusion: In conclusion, globular AL amyloidosis is a rare condition that may present as iron deficiency anemia arising from friable small bowel polypoid lesions. This diagnosis should be considered in the differential for patients presenting with chronic iron deficiency anemia.
Barrett's esophagus (BE) is the largest risk factor for esophageal adenocarcinoma (EAC), and the incidence of EAC has been increasing faster than any other malignancy in the US. Ablation after EAC is not well studied because treatments such as endoscopic resection and surgical esophagectomy, with or without chemoradiation (CRT), are effective modes of treatment. The case below is the first reported case of radiofrequency ablation of dysplastic BE using the Barrx Halo catheter in a patient who has undergone CRT for EAC. A 68 year old male with GERD presented for surveillance EGD revealing nodular BE. EMR of one nodule revealed poorly differentiated adenocarcinoma extending into the muscularis mucosa and lateral margin of sample. Surgery was deferred in consideration of his previous bariatric surgery due to a higher perioperative risk. EUS and PET CT showed no nodal or metastatic disease, and the patient opted for chemoradiation. A post CRT EGD showed extensive neovascular changes (Fig 1), and a 12cm segment of Barrett's esophagus. In consideration of the recent CRT, RFA for persistent BE was delayed 6 months. Using a Barrx probe, RFA was applied circumferentially at 12 joules/cm2 in the affected area (Fig 1).Figure 1Immediately after RFA, the patient complained of substernal chest pain. He presented to the ED where a CXR was performed showing no evidence of perforation and he was discharged with analgesia. He came to the office one week later with worsening chest pain and dysphagia/odynophagia to solids. A CT scan revealed marked thickening of the distal two thirds of the esophagus (figure 2). The patient was given a steroid taper to reduce inflammation. Repeat endoscopy two weeks later showed inflamed, thickened mucosa corresponding to the ablated areas (Figures 3). There was marked granulation tissue, but no ulcers, active bleeding or strictures. His symptoms began to improve and repeat CT showed slight improvement of esophageal wall thickening.Figure 2Figure 3BE persists in up to 93% of patients who receive only CRT for EAC, leaving these patients vulnerable to metachronous EAC. RFA was chosen as an effective and affordable means for eradication of BE. The persistent inflammation and poor healing that followed, however, suggests acquired hypersensitivity from prior CRT. Based on current literature and our experience, we recommend against the routine use of RFA for Barrett's ablation in patients with prior CRT for EAC.
Purpose: Diarrhea is one of the most common gastrointestinal complaints in a HIV patient and should not be taken lightly. Infectious etiologies should always be ruled out or treated for if the clinical scenario is appropriate. However, other less common causes of diarrhea should be considered in the differential diagnosis. We present a case of severe diarrhea in an HIV patient with recent ingestion of methamphetamine. A 31-year-old male with past medical history significant for HIV presented to the hospital with the complaint of diarrhea. The patient's most recent CD4 count was 350 and viral load was undetectable. He claimed to be compliant with his anti-retroviral therapy regimen that he had been taking for the last two years. Diarrhea was of sudden onset with duration of two days. Frequency of bowel movements was 12-15 times a day. Diarrhea was described to be watery. The patients denied rectal bleeding and episodes of melena. The patient denied recent fevers and chills. On examination, patient was found to be hypovolemic with positive orthostatics. Notable laboratory findings included hypokalemia and hypomagnesemia. The patient was started on aggressive intravenous hydration and electrolyte correction. Stool studies including bacterial culture, examination for ova and parasites, examination for ova and parasites was unremarkable. In addition, acid-fast smear was negative for Cryptosporidium, Isospora, and Cyclospora. The patient also underwent a flexible sigmoidoscopy with biopsy, which was also normal. After the extensive workup, alternative diagnoses were considered with a thorough social history. It was discovered that the patient has started taking methamphetamine prior to onset of diarrhea. Diarrhea had resolved at the third day of admission without any treatment except for supportive therapy. Since discharge, the patient has abstained from methamphetamine and has not experienced similar episodes of diarrhea. Diarrhea is a common complaint in HIV patients. The differential diagnosis is broad but it is prudent to search for underlying infectious etiologies for rapid initiation of antibiotic therapy. In this case, infectious workup was negative. Because there were no recent changes in medications, prescribed drugs was an unlikely cause of the acute diarrhea. The temporal relationship with methamphetamine ingestion and onset of diarrhea makes the illicit drug the most likely cause of diarrhea. The patient in our case underwent an extensive workup but with negative findings. Past case reports have illustrated an association between methamphetamine and ischemic colitis. In this case we propose that methamphetamine use can also lead to severe diarrhea.
Inflammatory bowel disease (IBD), Crohn's disease and ulcerative colitis are a common condition affecting 70-150 cases per 100,000 individuals. They are usually diagnosed in young adults between the ages of 15 and 30 years but can present at any age. The underlying causes are multi-factorial including genetic predisposition, immunologic defects and environmental factors. Acne vulgaris is a common skin condition affecting up to 80% of adolescents. Isotretinoin is a medication commonly used for the treatment of acne with gastrointestinal side effects that includes colitis, ileitis and colitis. There have been several case reports dating back over two decades of isotretinoin which question its causality in inducing or exacerbating inflammatory bowel disease. We present 7 patients with IBD who had documented exposure to isotretinoin prior to IBD diagnosis. The exact relationship between the use of the drug and timing of its introduction has raised substantial questions. These seven patients were retrieved from an ongoing database of 3,000 patients with IBD collected by the senior author. The average exposure to the acne medication is typically between 4-10 months. Three females and four males were identified with an average age of 51.4 years. Five patients had findings consistent with ulcerative colitis (specifically procto-sigmoiditis) while two patients had Crohn's disease. Endoscopic findings included erythema, friable mucosa and exudative polypoid lesions within the colon. The patients neither had a family history of inflammatory bowel disease nor were prescribed any other acne medications. Of the seven patients, two were treated with immunosuppressive drugs (6-MP/azathioprine) while five were on 5-ASA products. One patient required an ileocolic resection. From our data, there appears to be a more common association with isotretinoin and the development of left sided ulcerative colitis than with Crohn's disease. Isotretinoin may be the cause of IBD as none of the patients in our review had any family history or symptoms prior to exposure. Isotretinoin has the potential to cause or exacerbate existing colitis and is oftentimes overlooked by clinicians as an incendiary cause. Patients with pre-existing IBD should not ideally be prescribed isotretinoin. Retinoic acid affects intestinal epithelial growth, hinder cell repair and apoptosis. Retinoids also can decrease neutrophil chemotaxis. Patients should be informed of the risk of developing inflammatory bowel disease and advised to stop the medication if abdominal symptoms occur unless the acne is so severe, the risk is warranted. We now include regularly the history of acne and its treatment in all patients with IBD
Intussusception is a rare finding in adults presenting with abdominal pain. In the absence of obstruction, environmental factors should be investigated. Cannabinoid Hyperemesis Syndrome (CHS) and its relationship to intussusception in adults has not been established but should be considered if the clinical course matches the criteria and an obstruction has been ruled out. A recent article in The New York Times identified the syndrome as a commonly missed diagnosis that may affect an estimated 2.7 million Americans that are known to smoke marijuana. Patients present to the emergency department (ED) an average of 7 times before a diagnosis is made, expending up to $100,000 in medical resources. With the recent legalization of marijuana by many states, more patients are suspected to present with this syndrome. This case represents an example of how a delay in making a clinical diagnosis correlates to overtesting and rising medical costs. A 30-year-old female with a history of inhaled cannabis use since adolescence presented to the ED with abdominal pain, nausea, and vomiting. She has a history of multiple visits with similar symptoms in the last 3 years. Symptomatic relief at home was previously achieved with hot showers. The patient was managed for nausea and discharged home. The following day, she returned to the ED with severe abdominal pain and intractable vomiting. Abdominal CT revealed 3 jejunal intussusceptions:1 on the right and 2 on the left. Previous imaging on past presentations showed multiple intussusceptions along the small bowel, but a pathological lead point was never identified. She was admitted to the surgical unit and managed conservatively. On day 3, the abdominal pain subsided and repeat imaging showed resolution of all intussusceptions. Cannabinoid Hyperemesis Syndrome (CHS) is a phenomenon associated with long-term cannabis use. It can be diagnosed clinically by the following criteria: cannabis use, abdominal pain, nausea and vomiting, and symptom relief with hot showers and cannabis cessation. Our patient meets all of the criteria but the correlation to CHS was not previously considered, leading to repeat diagnostic testing and unnecessary hospital admission. In an economy where healthcare costs account for 17.9% of the GDP, reducing medical interventions that add low value to healthcare outcome is critical for the financial sustainability of our health systems. One solution lies in restoring the confidence of making a clinical judgment.3072_A Figure 1. Axial contrast enhanced CT scan of the abdomen showing a target-like mass in the small bowel, pathognomonic of intussusception.3072_B Figure 2. Ring-like configurations in the right and left mid abdomen showing evidence of additional intussusceptions (arrow).3072_C Figure 3. Sagittal contrast enhanced CT scan of the abdomen demonstrating a sausage-like mass, typical of a small bowel intussusception. No obstruction or lead point is identified.
While adhesions account for 70% of small bowel obstructions, they are less often seen in patients with no prior abdominal surgery. This in the past has led to a more conservative management of the condition rather than surgical intervention. Recent studies have shown that patients who present with small bowel obstruction secondary to adhesions, particularly those with no prior abdominal surgery, eventually require surgical intervention. This raises the question to whether small bowel obstruction in a virgin abdomen should initially be managed surgically to avoid complications that may arise when surgery is delayed. A 77 year old female with history of DM, HTN, CAD and CABG presented to the emergency department complaining of nausea, vomiting and abdominal pain. Patient's last bowel movement was 6 days prior, and had experienced multiple episodes of brown vomitus with no blood or mucus present. Patient endorsed diffuse abdominal pain, but denied any chest pain, shortness of breath, weight loss or headache. Patient confirmed no previous colonoscopy, abdominal surgeries and no significant family medical history. Laboratory findings reported a WBC of 13, and a 153 lipase. CT revealed that much of the small bowel was fluid filled, mildly distended, with multiple C shaped loops of small bowel in the right lower quadrant, all suggesting a closed loop obstruction. Due to the patient having no previous abdominal surgeries, there were concerns it would not resolve on its own. Patient was taken for emergent exploratory laparotomy2560_A Figure 1. Fluid-filled Distended BowelSmall bowel obstruction in an abdomen with no prior surgeries tends to be secondary to congenital bands. Patients presenting with small bowel obstruction are initially managed non-surgically due to concept of shorter hospital stay and a less invasive management, but new studies have indicated that those patients eventually require surgical intervention. A retrospective study performed on 72 patients with virgin abdomen showed that 60% of the patients required surgical intervention. Delay in operative treatment for small bowel obstruction has been shown to negatively affect the outcome. Another study found that old age and female gender were associated with delays in operative management. Delays varied from 5-16 hours and it correlated significantly with postoperative morbidity. We feel SBO in virgin abdomens should be studied in a large retrospective review to more adeptly guide their management.2560_B Figure 2. SBO secondary to adhesions
Purpose: Free air found on radiologic examination in the peritoneal cavity is normally a surgical emergency warranting exploratory laparotomy. The surgery carries with it subsequent perioperative and post-operative inherent risks. We report a case of a 73-year-old male who presents with persistent abdominal pain, visible distension, and bloating. The patient's past medical history is significant for Celiac disease confirmed by serology and biopsy; well controlled on a gluten free diet. The patient prior to presentation had Esophagogastroduodenoscopy (EGD) with no evidence of ulcer or perforation. Colonoscopy was unremarkable except for left sided diverticulosis and a small polyp. Small bowel capsule study revealed an area of erythema without frank perforation but was unable to complete evaluation of the distal bowel due to excess fluid and debris. Four computed tomography (CT) scans over the course of 3 years revealed overt free air in the peritoneum continuously with no obvious etiology, scattered diverticulosis but no diverticulitis, and small bowel thickening. The patient was not taken to surgery as it was felt that laparotomy would be unsuccessful as there was no obvious location of perforated viscus. Methods: Thus a double balloon enteroscopy (DBE) was chosen as a minimally invasive approach to evaluate the small bowel; the only area not completely evaluated by previous examinations. Upon introduction of the enteroscope into the proximal and mid jejunum, multiple wide mouth, large diverticula and smaller diverticula within larger diverticula were noted. A few of the more proximal diverticula had mucosa that appeared erythmematous with areas of dimpling and puckering; biopsies were taken. The larger diverticula were inspected and revealed no obvious perforations, bleeding, or purulent discharge. The peridiverticular regions of the mucosa were noted to have red punctate “spots” that were biopsied as well. Results: Upon withdrawal careful mucosal inspection revealed no masses or other lesions. Pathology demonstrated the biopsies to have acute on chronic inflammation with areas of focal cryptitis and capillary vessel congestion without any evidence of dysplasia. The diagnosis of microperforation of jejunal diverticula was made, and the patient was referred for surgical management. Conclusion: Jejunal diverticula are rare and usually occur in the elderly with an incidence between 1.3% and 4.6%. Perforation of jejunal diverticula is uncommon, which may be related to the low intraluminal pressures within the small bowel; thus having free air over the course of 3 years is extremely uncommon. Surgical resection is currently the standard of care and has been shown to be required in 8.5% of patients.
Purpose: A choledochal cyst is defined as a cystic dilatation of the extrahepatic and/or intrahepatic bile duct. These congenital ductal dilations occur in approximately 1:100,000 live births. Currently 6 types of choledochal cysts are described in the literature; but does not describe congenital dilations of the cystic duct. We present a case of a symptomatic cystic duct choledochocele diagnosed by endoscopic ultrasound (EUS) and resected laparoscopically. Methods: A 62 year old female presented for evaluation of right upper quadrant abdominal pain that was sharp, intermittent, most pronounced after eating, and associated with nausea and anorexia. On initial evaluation, the patient was afebrile, had RUQ tenderness to palpation without rebound or Murphy's sign. Labs revealed WBC elevation to 13,300, AST/ALT elevation to 477/182, alkaline phosphatase elevation to 186, and total bilirubin elevated to 3.2. CT scan revealed a distended gall bladder and a 2.8-cm rounded cystic lesion noted to be abutting the CBD. A right upper quadrant sonogram also noted the cystic lesion and was thought to represent a portion of the gallbladder or biliary tree. Results: For more precise visualization of the cyst, the patient underwent endoscopic ultrasound. An Olympus radial echoendoscope was used for the procedure. The pancreas neck, body and tail were identified and the duct was without dilation or stones. The gallbladder appeared enlarged with multiple small stones and sludge within the lumen. The cystic duct was grossly dilated to 2.6 cm. The cystic duct was identified by the presence of spiral of Heister. No mass or other lesion was identified within the gallbladder or cystic duct. There was no evidence of extrinsic compression of the gallbladder or cystic duct. The CBD and PD were completely normal, without stones or dilation. Conclusion: Laparoscopic removal was performed and patient did well after the resection. On gross review of the specimen a fusiform dilatation of the cystic duct was noted. The cystic duct shows a cystic area containing yellowgreen sludge measuring 2.8 cm. On follow up one month later the patient's pain and nausea symptoms were absent and lab values had normalized. This is the first case of cystic duct choledochocele confirmed with EUS and resected by laparoscopic surgery. The patient presented with biliary obstructive pain and an elevation in serum bilirubin, likely from compression of the cyst against the biliary tree. This case demonstrates a role that EUS can play in diagnosing abnormalities of the cystic duct. We propose including this anomaly in the biliary cyst classifications, which currently include only and intra/extra hepatic biliary cysts and fail to include cystic dilations of the cystic duct.
Purpose: Background: The mainstay of therapy for Gastrocutaneous (GC) fistulas has been surgical intervention. Routine endoscopic methods to close GI perforations currently used for management of perforations and fistula are not satisfactory due limitations. The Over the Scope Clip-OTSC system (OTSC(R)); is a new tool for the endoscopic entrapment of tissue. We present a case of an iatrogenic fistula successfully treated with the OTSC system for the first time in North America. Case: An 80 year old female presents with a long standing GC fistula. The patient had originally undergone a trans-esophageal echo (TEE) which resulted in an esophageal perforation. Post-surgical repair included placement of a feeding jejunostomy and venting gastrostomy tube. Subsequently the patient redeveloped the ability for oral diet, however despite extensive medical therapy, the GC fistula persistently drained after removal of the gastrostomy tube for 9 months. The OTSC system is composed of an application cap, which is mounted onto the distal tip of the endoscope and a connected releasing mechanism, installed on the handle of the scope. Two different variants of the clip, consisting of a shape-memory alloy (nitinol) are available: the “traumatic” and the “atraumatic” versions. There are two proprietary devices to draw the tissue into the cap; a tissue grasper or tripod device. The clip is deployed by stretching a wire with a hand wheel fixed on the access of the endoscope working channel. An Olympus endoscope was introduced through the mouth and advanced down to the level of a hiatal hernia sac where previously placed surgical sutures, esophageal perforation repair, were seen adjacent to the GEJ. The greater curvature revealed a retracted mucosal surface in continuity with the gastrostomy site on the outer abdominal wall. A savory guide wire was passed through the GC fistula through the abdominal wall and into the stomach. The scope was withdrawn and the OTSC system is mounted on the tip of the scope. The scope was passed to the level of the fistula. The targeted site of the fistula was grasped with the tripod device and brought into the cap. The Bear claw was deployed in excellent position. A second Bear claw device was deployed in the left aspect of the previously placed Bear claw. The savory wire was attempted to be passed through the skin into the stomach however couldn't be passed with Bear claw in position. Conclusion: Several case series have demonstrated the superiority of fistula closure via the OTSC system. This is the first case in North America to employ the system. We recommend the OTSC system for hemostasis, compression of large vessels, and closure of perforations and fistulas of the GI tract.
