Successful endoscopic removal of a hard rectal fecaloma using a needle-type knife and snare.

Esophageal Obstruction Secondary to Erosion of an Angelchik Prosthesis: The Role of Endoscopic Management

Biliary and pancreatic stone extraction devices

Introduction: Rectal foreign bodies are a relatively rare entity; examples include plastic/glass bottles, cucumbers, carrots, or rubber objects. Swallowed objects such as fish bones are occasionally found in the rectum; those that do not pass with the stool have a tendency to develop complications including intestinal perforation, enterovesical fistulas, and perianal abscesses. Previously reported rectal foreign bodies have been removed transanally with anal dilation and via laparotomy. We present an unusual case where a fish bone was successfully removed from the rectum endoscopically using a foreign body hood protector. Case Report: A 46-year-old male with a past medical history of hypertension, diabetes, and hemorrhoids presented to the ED of our facility with rectal pain 4 days after swallowing a fish bone. Four days prior to presentation, a butterfish got “stuck” in the patient’s esophagus, which eventually passed with copious liquid ingestion. The patient attempted to relieve his rectal pain with hemorrhoidal suppositories without improvement. Vitals were stable in the emergency department, and abdominal exam was unremarkable. A sharp linear object was felt along the wall of the anal canal on rectal exam upon which the emergency department physician reported cutting her finger. An abdominal x-ray demonstrated a linear opacity in the rectum approximately 2 cm in size with no evidence of obstruction or perforation. A thin, flat triangular bone with sharp tips and lateral projections was visualized laying against the mucosa during flexible sigmoidoscopy. The bone was gently maneuvered into the rectum with the endoscope and was safely removed using rat tooth forceps and a foreign body hood protector to protect the anal canal. No mucosal tears or perforations occurred; the patient was discharged home without complications. Discussion: The foreign body hood protector is a small bell-shaped latex rubber protector that was designed to be placed over an endoscope in a folded back position to protect the mucosa of the gastrointestinal (GI) tract from the sharp edges of a foreign body during its removal. This rubber hood is generally used to protect the esophagus and posterior pharynx during foreign body removal from the upper GI tract. Case reports have demonstrated successful rectal foreign body, such as fish bone, removal transanally with anal dilatation. This case is unique as it demonstrated the successful endoscopic rectal fish bone removal just by thinking “out of the box.”

Biliary cast syndrome (BCS) is an uncommon complication which is mostly described in orthotopic liver transplantation. However, BCS has also been reported rarely in non-liver transplant patients. We describe a male long-term opium inhaler with BCS who underwent successful endoscopic cast removal by balloon enteroscopy-guided endoscopic retrograde cholangiopancreatography. A 52-year-old man, who was a known case of opium addiction, presented with the chief complaint of epigastric pain for 1 week prior to admission. Routine laboratory evaluation revealed cholestatic liver enzyme elevation. A cholestatic pattern was seen in radiographic modalities. Endoscopic retrograde cholangiopancreatography showed a linear filling defect in the intra- and extrahepatic duct. A long biliary cast was successfully removed using an extractor balloon. After removal of the biliary cast the patient is receiving ursodeoxycholic acid and does not report any problem 4 months after treatment. It seems that biliary dyskinesia due to long-term opium use can be a predisposing factor for biliary cast formation.

We described herein a 54-year-old male with gastric perforation secondary to an ingested fish bone presenting with marked pain in the epigastric area. Plain abdominal film revealed a radiopaque object in the left upper quadrant, but it was missed clinically. Subsequently an upper gastrointestinal endoscopy was performed revealing a fish bone embedded in the antrum of the stomach with a 1.5-cm free end in the gastric lumen. The fish bone measuring 3.5 cm in length was successfully removed using a polypectomy snare. No evidence of bleeding was found from the perforating site of the stomach after extraction of the impacted fish bone. Subsequently, no peritoneal sign was found and abdominal ultrasound showed no ascites. After conservative treatment, the patient was discharged on the 4th hospital day. There was no recurrence of abdominal pain after one-month follow-up.

INTRODUCTION: ERCP is an essential tool in the management of biliary disorders. A large variety of rare ERCP related complications have been reported such as an impacting a retrieval basket, and colonic perforation. We report an unusual complication of ERCP with a retained balloon and a successful endoscopic removal at subsequent ERCP. CASE DESCRIPTION/METHODS: A 61-year-old man was transferred from a local hospital after undergoing an ERCP for choledocholithiasis. The ERCP balloon became lodged in the bile duct during stone extraction. The endoscopist tried to retrieve the balloon by pulling on the external part of the balloon catheter, but the catheter broke. He aborted the procedure and removed the ERCP scope by cutting the balloon catheter from outside and pulled the scope out. The patient was left intubated with the balloon catheter in his mouth and was transferred to our facility. Upon arrival, the patient was taken for ERCP. A fluoroscopic film showed the extraction balloon in the right upper quadrant of the abdomen (Figure 1). The duodenoscope was introduced through the mouth next to the balloon catheter. The impacted balloon was seen emerging from the major papilla (Figure 2). It was compressing the upper ampulla, duodenum, and stomach leading to linear pressure erosions (Figure 2). We used the Spyglass direct visualization system ((Boston Scientific, Marlborough, Mass, USA) to visualize the balloon impaction site, which was obstructed by the balloon catheter and the stone (Figure 3). The bile duct was then cannulated using a 0.025-inch × 270 cm angled ERCP guidewire (Olympus VisiGlide) through a 3.9 Autotome sphincterotome (Boston Scientific). The CBD was moderately and diffusely dilated. The impacted balloon catheter was pulled using the external part of the catheter, and it was successfully removed. We placed one fully covered self-expandable metal stent (FCSEMS) (Wallflex, Boston Scientific)10 mm by 4 cm with one 7 Fr by 10 cm double pigtail plastic stent into the CBD to maintain adequate drainage. The ERCP was accomplished without difficulty. The patient was extubated, liver function test improved. He was discharged home in a stable condition. He will have repeated ERCP in 8 weeks to remove the stents. DISCUSSION: Retaining ERCP balloon during stone extraction is extremely rare because it is easy to deflate and remove. Up to our knowledge, it has not been reported in the literature. We have demonstrated a successful retrieval of retained ERCP balloon during stone extraction. Watch the video: http://bit.ly/2JUie2Q.

The treatment of chronic pancreatitis (CP) and symptomatic pancreatic duct (PD) calculi often involves techniques like endoscopic retrograde cholangiopancreatography (ERCP), extracorporeal shock wave lithotripsy (ESWL), or a combination of both. However, identifying predictive factors for the successful removal of these calculi remains variable. This study aimed to determine the factors predicting successful ESWL and endoscopic removal in CP and PD calculi patients. We examined data from CP patients who underwent complete PD calculi removal via ESWL combined with ERCP between July 2012 and 2022, and assessed baseline characteristics, imaging findings, and treatment details. Patients were categorized into early- and late-endoscopic complete removal groups (EER and LER groups, respectively). Of the 27 patients analyzed, 74.1% were male with an average age of 44 ± 9.6 years. EER was achieved in 74% of the patients. Patients in the EER group exhibited smaller PD calculi diameter (8.5 vs. 19 mm, p = 0.012) and lower calculus density (964.6 vs. 1313.3 HU, p = 0.041) compared to the LER group. Notably, PD stricture and the rate of PD stent insertion were not different between the groups. A calculus density threshold of 1300 HU on non-contrast CT demonstrated 71% sensitivity and 80% specificity in predicting EER. Smaller and low-density PD calculi may serve as predictors for successful EER, potentially aiding in the management of CP patients with PD calculi.

BackgroundThis report describes a rare case of a wooden toothpick embedded in the bladder muscular layer and shares the experience of successful diagnosis and treatment.Case presentationA 29-year-old female patient with a history of cesarean section was admitted due to persistent lower abdominal pain and dysuria lasting one month. Preoperative three-dimensional CT imaging was performed, using a crucian carp with an inserted injection needle as a density reference. Density comparisons between the foreign body, needle, and fishbone suggested that the foreign body was unlikely a retained needle or fishbone. Considering the patient's dietary habits, it was suspected that the object was an accidentally swallowed wooden toothpick. The patient underwent ultrasound-guided transurethral surgery, during which a wooden toothpick approximately 3.4 cm long, 4 mm wide at its midsection, with a rough surface, was successfully removed. Postoperative imaging confirmed the complete removal of the foreign body, and the patient recovered well. During a six-month follow-up, the patient reported no urinary or abdominal symptoms.ConclusionA detailed patient history and imaging studies are crucial for diagnosing unexplained bladder foreign bodies. Ultrasound-guided transurethral cystoscopic surgery is an effective method for removing bladder foreign bodies. This case provides valuable insights for managing and treating similar complex cases.

The majority of ingested foreign bodies will pass safely through the gastrointestinal tract, but long and rigid foreign bodies are associated with an increased risk of gastrointestinal impaction, perforation and bleeding. However, large foreign bodies which have been swallowed can remain trapped in the stomach over a longer period of time without any significant symptoms. This case report describes the case of a 36-year-old man addicted to heroin who purposefully swallowed a lighter (double wrapped in cellophane) and presented with hematemesis and melena 17 months after the ingestion of the foreign body. The lighter was successfully removed via flexible endoscopy using a polypectomy snare. Swallowed long and rigid foreign bodies trapped in the stomach over a long period of time always represent a special clinical and endoscopic challenge. In cases where endoscopic removal fails, a laparoscopic surgical approach may be an alternative.

INTRODUCTION: Toothbrush ingestion is uncommon and can sometimes be seen in patients with eating disorders or underlying psychiatric illness. Although some foreign bodies can pass spontaneously, due to its shape, spontaneous passage of toothbrush can be difficult and if left untreated can lead to abdominal pain, mucosal ulceration, bleeding and perforation. We report one such case of a toothbrush accidentally ingested 15 years ago and impacted in the gastric wall that was successfully removed endoscopically. CASE DESCRIPTION/METHODS: A 37-year-old female with past medical history of bulimia and accidental ingestion of tooth brush 15 years ago reported to her PCP with worsening abdominal pain. She had never reported or sought help for her ingested toothbrush all these years due to fear of being labelled mentally ill. Labs were relevant for mild anemia with Hb of 10.5 gm/dl. Initial attempt at endoscopic removal at outside center was unsuccessful. At repeat EGD at our center, a 20 cm long toothbrush was seen in the gastric body covered with significant debris (Figure 1). The distal end of the toothbrush was seen embedded in the proximal gastric wall (Figure 2). Attempts to free the distal end with a snare were not successful. A long overtube was then placed and gastroscope passed through it. Then using a rat tooth forceps the bristle part of the tooth brush was grasped and the brush was pulled into the antrum and the distal end was freed from the gastric wall. No frank perforation was seen at the site of impaction. The tooth brush was then grasped with a snare and brought into the overtube. The endoscope and overtube with the toothbrush were successfully removed (Figure 3). The patient was continued on PPI for 4 weeks and her abdominal pain resolved post procedure. DISCUSSION: Up to 80% of the ingested foreign bodies may pass through the gastrointestinal tract spontaneously. However long objects (>5 cm) cannot pass through the duodenum and need to be removed by endoscopy and rarely by surgery. Those that remain in gastrointestinal tract can be associated with serious complications such as perforation, bleeding, pressure necrosis or obstruction. Toothbrush ingestion is uncommon and requires prompt removal. However our patient sought help after 15 years of ingestion only after it caused abdominal pain. To the best of our knowledge this is the longest time period a toothbrush has been reported retained in the stomach and subsequently successfully retrieved by endoscopy.

Most ingested foreign bodies will pass uneventfully through the gastrointestinal tract. Nevertheless, long and rigid foreign bodies are associated with an increased risk of gastrointestinal impaction, perforation and bleeding. Moreover, there has been no case of spontaneous passage of a toothbrush reported. Therefore, the prompt removal of such ingested foreign objects is recommended before complications develop. This case report describes a case of an 18-year-old woman who accidentally swallowed her toothbrush. The toothbrush was successfully removed via flexible endoscopy using a polypectomy snare. A swallowed toothbrush is a special clinical challenge. Early endoscopic retrieval of the toothbrush is critical for reducing morbidity and mortality. In cases when endoscopic removal fails, a laparoscopic surgical approach may be an alternative.

Most ingested foreign bodies (FBs) pass through the gastrointestinal tract without any problems, although their passage depends on shape and size. When a FB is relatively large, endoscopic removal may be utilized in most cases (the success rate was 95%), but sometimes surgery is required. We present a case report of a 27-year-old woman with epilepsy who had swallowed a fork in a suicide attempt. A plain abdominal radiograph confirmed a FB (fork) in the stomach with no visible pneumoperitoneum. On objective examination, the abdomen was soft and nontender with no peritoneal irritation. After a failed attempt at endoscopic removal, the laparoscopic intervention was undertaken. The operation was performed under general anesthesia utilizing open laparoscopy (Hasson's technique). As a result, the fork was successfully removed without further complications. After 72 h, she was discharged from the hospital without any complications. The patient was followed up after 4 weeks and made a full recovery.

Older patients with simultaneous main bile duct and gallbladder stones, especially those with high-surgical risks, create a common clinical dilemma. After successful endoscopic removal of main bile duct stones, should these patients undergo laparoscopic cholecystectomy to reduce risk of recurrent biliary events? In this population-based cohort study, we report long-term outcomes of a wait-and-see strategy after successful endoscopic extraction of main bile duct stones. Consecutive patients 75 years or older undergoing endoscopic stone extraction without subsequent cholecystectomy in two tertiary academic centers between January 2010 and December 2018 were included. Primary outcome measure was recurrence of biliary events. Secondary outcome measures were operation-related morbidity and mortality. A total of 450 patients (median age, 85 years; 61% female) were included, with a median follow-up time of 36 months (0-120 months). Recurrent biliary events occurred in 51 patients (11%), with a median time from index hospital admission to recurrence of 307 days (12-1993 days). The most common biliary event was acute cholecystitis (7.1%). Twelve patients had cholangitis (2.7%) and two biliary pancreatitis (0.4%). Only one patient (0.4%) underwent surgery due to later gallstone-related symptoms. Eighteen patients (4.0%) required endoscopic intervention and 16 (3.5%) underwent surgery. There were no operation-associated deaths or morbidity among those undergoing later surgical or endoscopic interventions. In elderly patients, it is relatively safe to leave gallbladder in situ after successful sphincterotomy and endoscopic common bile duct stone removal. In elderly and frail patients, a wait-and-see strategy without routine cholecystectomy rarely leads to clinically significant consequences. Therapeutic/Care Management; Level III.

Patients with Billroth II (B-II) gastrectomy present technical difficulties during endoscopic stone removal due to altered anatomy. Although endoscopic sphincterotomy alone or endoscopic balloon dilation alone has been used for removal of bile duct stones in patients with B-II gastrectomy, the results are not satisfactory. The aim of this study was to evaluate the efficacy and safety of endoscopic papillary large balloon dilation (EPLBD) for removal of bile duct stones in patients with B-II gastrectomy. Twenty-six patients (20 men and six women; median age 72 years) with bile duct stones and a history of B-II gastrectomy were enrolled. After cannulation, limited endoscopic sphincterotomy was performed. Then, balloon dilation (balloon size, 10-15 mm) was performed and stones were removed conventionally or via mechanical lithotripsy. Successful stone removal and complications were evaluated. In all cases, stones were successfully removed. The median number of sessions for complete stone removal was one (range 1-3). Stone removal by mechanical lithotripsy was achieved in three patients (11.5%). There were no significant complications, such as bleeding, pancreatitis, or perforation. Endoscopic papillary large balloon dilation is an effective and safe method for removal of bile duct stones. We suggest consideration of this technique for removal of bile duct stones in patients with B-II gastrectomy.

Intravariceal cyanoacrylate injection is a highly effective and safe procedure for the treatment of bleeding gastric varices. Nevertheless, some cases of severe cyanoacrylate-specific complications due to embolization have been described. Technical difficulties, including risk of sclerotherapy needle clogging, and cyanoacrylate sticking to the tip and the accessory channel of the endoscope, have been mentioned in other reports. We report a case in which a sclerotherapy needle that remained stuck in gastric valves after bucrylate injection was successfully removed by laser disintegration of the cyanoacrylate clot.