Bulb Ulcer Research Articles

Retroperitoneal Teratoma and Ganglioneuroma: A Rare Tumor in a Woman With Gastric Outlet Obstruction

Mature teratomas and ganglioneuromas are rare benign tumors that are found in young female patients. We present a rare case of a complex retroperitoneal mass composed of a teratoma and ganglioneuroma in a young woman with gastrointestinal symptoms. A 28-year-old woman presented with abdominal distension for one year. She complained of intermittent episodes of abdominal bloating and early satiety, which was relieved by fasting. She had frequent nausea and vomiting of partly digested food. She reported a 20 pound weight loss. She had no significant past medical history and denied using alcohol or any recreational drugs. On initial assessment patient had stable vital signs. Physical examination was notable for tympanic abdomen and diminished bowel sounds. Laboratory studies revealed hemoglobin of 9.7gm/dl with MCV of 85.3, normal comprehensive metabolic panel and a negative beta-HCG. CT abdomen was done and revealed a markedly distended stomach and a hypodense para-aortic retroperitoneal heterogeneous mass in the proximity of the stomach and the left adrenal gland encasing the celiac axis and superior mesenteric artery. Nasogastric tube was inserted and provided immediate relief of symptoms. EGD was performed and showed pyloric stenosis and a large duodenal bulb ulcer with extensive duodenal edema. EUS showed a hypoechoic mass near the gastric body. FNA sampling was non diagnostic. Stomach biopsies were positive for H. pylori. After discussion with the surgery team, patient was taken for an open biopsy. A large well-encapsulated para-aortic mass was visualized and completely resected. Duodenum was found to be extremely thick and strictured, therefore a gastrojejunostomy was additionally performed. Biopsy of the mass revealed components of mature cystic teratoma and ganglioneuroma. Patient did well postoperatively and was discharged home to complete H. Pylori treatment. Teratomas contain cell types derived from one or more of the three germ cell layers. Ganglioneuromas are benign tumors composed entirely of ganglion cells and found along sympathetic nerve plexus. These tumors can cause symptoms, such as gastric obstruction, when they compress surrounding organs. It is extremely rare to find teratomas and ganglioneuromas within same mass structure. Treatment of both teratoma and ganglioneuroma tumors is surgical resection. Some experts recommend periodic radiologic surveillance due to potential metastatic potential of these tumors.2617 Figure 1. CT scan of the retroperitoneal mass in paraaortic region

Black Esophagus and Necrotic Duodenum Masquerading as New Onset GERD

Background: Black esophagus is a rare finding of acute esophageal necrosis that was first described endoscopically in 1990 by Dr. Goldenberg. It is characterized by circumferential black esophageal mucosa in the distal portion of the esophagus, with an abrupt transition to normal mucosa at the gastroesophageal junction. Case Presentation: A 74 year-old obese male presented to his primary care physician for new onset epigastric burning pain. He was prescribed omeprazole once daily, which fully resolved his epigastric pain within one week. The patient self-discontinued omeprazole seven days later and had a rapid reoccurrence and worsening of his epigastric burning sensation. This prompted his decision to present to the Emergency Room. A CT abdomen/pelvis with oral contrast showed new moderate ascites and circumferential wall thickening at the distal esophagus and mid-jejunum. The EGD demonstrated an adherent circumferential white plaque from 22-25cm. In the distal 1/2 of the esophagus, there was a transition to diffuse black mucosa that continued to the GEJ. Within the distal half of the esophagus there were four large columns of varices without high risk stigmata. At the GEJ there was an abrupt conversion to normal appearing mucosa. Esophageal biopsies demonstrated ulcerated squamous mucosa with fungal organisms. Within the stomach there was moderate portal hypertensive gastropathy. The duodenal bulb had mild erythema but was otherwise normal. Starting in the duodenal sweep and extending to the 3rd portion of the duodenum there were several dozen scattered clean-based ulcers varying in size from 2-15mm. There were also one dozen eschar/necrotic lesions ranging 5-10mm and diffuse mucosal edema and erythema with easy tissue friability. Duodenal biopsies showed non-specific acute inflammation, negative for CMV, dysplasia, malignancy or amyloid. A MRI abdomen with IV contrast demonstrated intrahepatic portal vein thrombosis, as well as chronic thrombosis of the splenic vein and superior mesenteric vein. Esophageal and paragastric collaterals were present. The liver demonstrated subtle nodular contour. Discussion: Acute esophageal necrosis (AEN) is a rare endoscopic finding that manifests preferentially within the distal esophagus, often as a result of tissue ischemia. Duodenal bulb ulcers and erosions are not an uncommon finding in these patients. Our case is unique because of the simultaneous necrotic involvement within the 2nd and 3rd portion of the duodenum.1763_A Figure 1. Mid-Esophagus1763_B Figure 2. GEJ1763_C Figure 3. Duodenum, 2nd portion

Frequency of Gastrointestinal Diseases in Patients with End-Stage Renal Disease Treated with Long Term Dialysis

Background: Gastrointestinal complications are frequent in patients with renal disease and are responsible for substantial morbidity and mortality among these patients in developing countries. Many times, these patients are subjected to endoscopic evaluation and mucosal biopsies are taken for definitive diagnosis. Long before the routine uses of dialysis, patients dying of uremia were found to have a high incidence of gastrointestinal abnormalities (1).Matherials and methods: The survey included 240 persons; 120 of them were dialysis patients, while the remaining 120 were healthy individuals who served as a control group. 54 (45%) of the patients with hemodialysis were females while 66 (55%) of them were males with mean age: 58.20 ± 18.00 years. These patients had been in dialysis for more than 12 years at the Clinic for Nephrology in Skopje and the Clinical Hospital in Tetovo.Results: Gastrointestinal complications were present in 20 (37.0%) out of 54 females while 26 (39.4%) out of 66 males presented with duodenal bulbar ulcers. 84 patients [(females-38/54 (70.4%) and males-46/66 (85.2%)] of the total number of 120 examined patients were found to have chronic gastritis.In conclusion, we found that the incidence of PUD was more than 10 times higher in CKD patients than in those without CKD over a 3-year period between 2008-2010. CKD patients receiving HD, NSAID, or clopidogrel had an increased risk of PUD, compared to CKD patients not receiving these treatments.

A Rare Complication of Recurrent Duodenal Ulcer

Question: A 92-year-old man presented to our emergency department owing to black stool passage for 3 days with general fatigue. He had history of bilateral renal cysts and duodenal bulb ulcer bleeding post suture ligation 6 months ago. On examination, his conjunctiva were pale and his abdomen was soft without tenderness. Digital rectal examination revealed tarry stool. Laboratory data exhibited anemia (hemoglobin, 6.9 g/dL). Esophagogastroduodenoscopy revealed a 2.5-cm bleeding ulcer at the distal bulb and one 1-cm outpunching area at the proximal second portion of the duodenum with internal debris (Figure A, B). Computed tomography (CT) of the abdomen (Figure C) and further upper gastrointestinal series were performed (Figure D, E). What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. A CT of the abdomen revealed a 5.4-cm right renal cystic lesion with internal food material and gas pockets that is connected to the second portion of the duodenum (Figure C, arrow). Further upper gastrointestinal series disclosed a focal out-pouching with contrast accumulation arising from the second portion of duodenum and pointing posteriorly (Figure D, E), compatible with a duodenal-renal fistula as diagnosed in CT study. The inflammatory response to a penetrating peptic ulcer can lead to the formation of a fistula between the duodenum and any structure nearby. Fistulae to the biliary tract and colon has been described more commonly. Duodenal-renal fistulae owing to peptic ulcer disease is very rare and unique. The patient was transferred to general surgeon and he was discharged eventfully 34 days later under conservative treatment.

Etiological Analysis of 419 Cases of Digestive Tract Hemorrhage

Aim: To study common cause of digestive tract hemorrhage and the relationship between etiology and age. Methods: Retrospective analysis about the data of 419 cases of digestive tract hemorrhage in digestive internal medicine from January 2016 to January 2018 in Jingzhou Central Hospital. Results: 419 cases of digestive tract hemorrhage include 305 cases of hemorrhage in upper digestive tract and 114 cases of hemorrhage in lower digestive tract. The first 5 causes of upper digestive tract hemorrhage in middle-aged and young group were: duodenal bulb ulcer, gastric ulcer, esophageal and stomach bottom varices bleeding in cirrhosis of schistosomiasis, compound ulcer, esophageal and stomach bottom varices bleeding in hepatitis B cirrhosis. The first 5 causes of upper digestive tract hemorrhage in elderly group were: gastric ulcer, duodenal bulb ulcer, esophageal and stomach bottom varices bleeding in hepatitis B cirrhosis, esophageal and stomach bottom varices bleeding in cirrhosis of schistosomiasis, gastric cancer. The first 5 causes of lower digestive tract hemorrhage in middle-aged and young group were: ulcerative colitis, colorectal polyps, hemorrhoids, crohn’s disease, ischemic bowel disease. The first 5 causes of lower digestive tract hemorrhage in elderly group were: colorectal polyps, colon cancer, ulcerative colitis, ischemic bowel disease, hemorrhoids. Conclusion: In the cases of upper digestive tract hemorrhage, peptic ulcer should be paid attention to in middle-aged and young people, and elderly should be noted in gastric cancer. Ulcerative colitis should be paid attention to in middle-aged and young people with lower digestive tract hemorrhage, and elderly should be noted in colorectal polyps and colon cancer.

An Atypical Place for Amyloidosis

Amyloidosis is the abnormal extracellular tissue deposition of insoluble, pathologic fibrils composed of antiparallel beta-pleated sheets. Deposition can be systemic or organ-specific. Symptomatic gastric amyloidosis is rare given that only 0.08% of those afflicted with the disease demonstrate gastrointestinal bleeding, malabsorption, protein-losing gastroenteropathy, and chronic gastrointestinal dysmotility. A known correlation exists between multiple myeloma and amyloidosis. This is a case of a 75 year old male with multiple myeloma who was found to have gastric and duodenal amyloidosis on evaluation of nausea, abdominal pain and dysphagia with EGD. For his multiple myeloma the patient underwent treatment for several months with dexamethasone, cyclophosphamide, and bortezomide. On a follow up visit, he endorsed several weeks of nausea, epigastric abdominal pain and dysphagia (mainly to solids) and thus EGD was performed. He was found to have a mild, non-obstructing Schatzki ring at the gastroesophageal junction. It was dilated to a maximum TTS balloon size of 20mm with complete resolution of luminal narrowing. He was also found to have localized moderately erythematous mucosa without bleeding in the gastric antrum as well as two 5mm non-bleeding cratered duodenal bulb ulcers with no stigmata of bleeding. These sites were biopsied and confirmed to have abundant amyloid deposition in the lamina propria via the Congo red special stain. Amyloid deposition can occur in the lower esophageal sphincter thereby decreasing lower esophageal sphincter pressure and cause symptoms of dysphagia and acid reflux, however typical symptoms of gastrointestinal amyloidosis include hematochezia, melena, malabsorption and dysmotility. Gastric amyloidosis, though rare, should be considered on differential diagnosis in individuals with known multiple myeloma who present with nausea, abdominal pain and dysphagia.

The Double Pylorus

88 year female with medical history of hypertension, type 2 diabetes mellitus, hyperlipidemia, osteoarthritis, gastroesophageal reflux disease and a vague history of peptic ulcer disease (PUD) presented to emergency department with 2 episodes of black stool and increasing fatigue over the past 3 days. She also reported using ibuprofen regularly for osteoarthritic related symptoms. Physical exam and basic laboratory investigations were also normal with the exception of hemoglobin, which was 7g/dL. Esophagogastroduodenoscopy (EGD) demonstrated a large non-bleeding ulcer (15mm in largest dimension) in the antrum. Notably, there was also a second luminal opening between the antrum and duodenal bulb adjacent to the ulcer consistent with a double pylorus (see Fig. 1 and Fig. 2). Double pylorus is a rare endoscopic finding, found in 0.001% to 0.4% of EGD. It is characterized by two openings between the distal stomach and the duodenal bulb. It can be classified as congenital or acquired based on etiology. Congenital double pylorus is usually found in association with other congenital anomalies like heterotopic pancreatic tissue, pancreatic divisum or gastric duplication. The acquired double pylorus (ADP) is usually associated with PUD and results from a prepyloric ulcer or duodenal bulb ulcer eroding into the duodenum or stomach creating a fistulous opening. Additionally, the use of NSAIDS, corticosteroids and persistent H. pylori infection can affect the healing of ulcers and can lead to ADP. Diagnosis is made by endoscopy or occasionally by radiography with the lesser curvature of stomach being the most common location of these fistulous openings. Double pylorus should be differentiated from a gastric diverticulum during endoscopy and can also be mistaken with a large mucosal fold, tumor or polyp during evaluation with upper gastrointestinal series. Treatment of double pylorus consists of promotion of mucosal healing with proton pump inhibitor and less commonly H2 blockers, avoidance of NSAIDS/corticosteroids, and treatment of H. pylori infection. The majority of fistulas do not close (or may only partially close), however endoscopic division of the bridging tissue with a sphinterotome should be considered for patients presenting with gastric outlet obstruction. Surgical intervention is an option for patients with obstruction refractory to endoscopic treatment or the presence of other complications such as perforation or refractory bleeding.Figure: Second luminal opening between the antrum and duodenal bulb adjacent to the ulcer consistent with a double pylorus.Figure: Second luminal opening between the antrum and duodenal bulb adjacent to the ulcer consistent with a double pylorus.

A Rare Case of Primary Hepatic B-cell Lymphoma and Upper Gastrointestinal Hemorrhage

Diffuse large B-cell lymphoma (DLBCL) is the most common histologic subtype of non-Hodgkin lymphoma(NHL) accounting for approximately 25 % of all NHL cases. Extranodal extramedullary involvement occurs in up to 40% of cases. The most common site for extranodal extramedullary lymphoma is the stomach. Primary hepatic lymphoma is rare with a prevalence of 0.4% among extranodal NHL and 0016% among all NHLs. We hereby present a rare case of a 70-year old female with diffuse large B-cell lymphoma of the liver who had a metastasis to stomach resulting in a gastric ulcer. 70-year old female with a history of chronic hepatitis B infection, hypertension, recent admission for deep vein thrombosis (on Lovenox) and recently diagnosed via liver biopsy, of DLBCL of the liver presented to our hospital with episodes of melena and sharp epigastric pain after meals, for 1 week duration. The patient denied having any other complaints. Physical exam was unremarkable except distended abdomen with palpable epigastric abdominal mass and negative rectal exam. Lab results were significant for Hgb 7.1 of gm/dL, LDH of 2200 U/L, mildly elevated AST, ALT and ALP and normal total and direct bilirubin levels. Endoscopy was performed which revealed clean based ulcer of 6 mm x 4 mm in the body of stomach, with heaped margins and surrounding erythema with no signs of active bleeding, moderate size flat clean based duodenal bulb ulcer and sub-mucosal raised nodule of 6 mm x 3 mm in 2nd portion of the duodenum. Biopsy from gastric ulcer was determined to be positive for DLBCL with the similar pattern as seen in a Liver biopsy. Review of literature indicates that there are no reported cases of primary hepatic lymphoma presented with gastric ulceration and secondary gastrointestinal hemorrhage. Moreover, it should be known that the association found in the case presented carries morbidity and should be listed as part of a working differential in a patient with Hepatic B-Cell Lymphoma who are admitted with gastrointestinal hemorrhage.Figure

The Role of a Gastroenterologist in Detection of a Hypopharyngeal Cancer: A Case Report

Introduction: Current guidelines do not recommend routine oropharyngeal evaluation on esophagogastroduodenoscopy (EGD). We present a case of hypopharyngeal cancer missed on two consecutive EGDs.Figure: Hypopharyngeal mass as seen during the EGD.Case: A 71-year-old male with history of prostate cancer status post radiation therapy presented with complaints of globus sensation, and gradually worsening dysphagia and odynophagia to solids and liquids for 2 months. He denied food regurgitation, heartburn, hematemesis, melena, allergies, weight loss, smoking or alcohol consumption. An EGD was performed which showed LA grade D esophagitis, small hiatal hernia and a duodenal bulb ulcer. He was started on high dose proton-pump inhibitors. Biopsies were negative for H. pylori. A repeat EGD after 2 months showed good resolution of esophagitis and well healed duodenal ulcers, as well as esophageal biopsies were negative for eosinophilic esophagitis. The patient's dysphagia persisted and further work up with an esophagram and a motility study were unrevealing. A third EGD was performed for attempted impedance evaluation to assess for association of reflux symptoms. Upon insertion of the endoscope in the hypopharynx, a 2cm friable, non-ulcerated hypopharyngeal mass was observed. Results of the biopsies revealed invasive poorly differentiated squamous cell carcinoma. A direct laryngoscopy confirmed the mass was originating from the post-cricoid mucosa, posterior to the arytenoids without arytenoidal mucosal involvement. A PET/CT scan was done and the tumor was classified as T1N0M0. Patient received radiation therapy with resolution of symptoms. Discussion: Hypopharyngeal cancers (HPC) are aggressive with majority diagnosed at advanced AJCC stages III or IV. Diagnosis of HPC at earlier stages might improve survival outcomes. In US, 7 million routine EGDs are performed per year. Oropharyngeal structures are also visible during EGDs. Therefore, EGDs could be a valuable tool in HPC screening, especially in high-risk patients. Currently, there are no guidelines regarding routine evaluation of the oropharyngeal anatomy during EGD. Since prior EGDs had missed the HPC lesion, this case raises several important questions. Should complete visualization of the oropharyngeal structures be part of a routine EGD? Does prolonged oropharyngeal evaluation during EGD raise the aspiration risk? Are there any specific sedation protocols better suited for oropharyngeal evaluation? Further studies are required to answer such questions.

A Case of Poorly Differentiated Adenocarcinoma with Signet Ring Cell Carcinoma of the Duodenal Bulb: A Case Report

Duodenal cancers are rare. Histopathologically, most duodenal cancers are adenocarcinoma. Signet ring cell carcinoma (SRCC) is a rare tumor more commonly found in the stomach than at other sites in the digestive tract. SRCC is extremely uncommon in the duodenum, with most of these tumors occurring in the ampulla. Until now, there are few case reports of duodenal cancers with SRCC. To accumulate case reports, we report a rare case of nonampullary duodenal bulb SRCC. A 74-year-old man was admitted to our hospital with melena. Esophagogastroduodenoscopy (EGD) showed a duodenal bulb ulcer. He was treated with a proton pump inhibitor. However, 1 month later, he was readmitted to our hospital with epigastric pain and nausea. A second EGD examination showed an ulcer at the duodenal bulb. Biopsies taken from the ulcer showed SRCC. Distal gastrectomy and duodenal bulb resection were performed. Histologic examination of the specimen showed a type 4 lesion located from the duodenal bulb to the pyloric antrum. The tumor was composed of poorly differentiated adenocarcinoma (por) with SRCC. The distal margin of the duodenal bulb was invaded with tumor. Therefore, pancreatoduodenectomy was performed. One year after the initial operation, he is alive and had no relapse. We described a rare case of por with SRCC of the duodenal bulb. It is important to bear in mind that an ulcer following an abnormal clinical course should be biopsied, and we have to select a suitable operation in cases of duodenal bulb cancer.

Endoscopic Evaluation by Lanza Score of The Upper Gastrointestinal Bleeding in Patients Under Long-term Low-dose Aspirin for The Prevention of Cardiovascular Events

introduction: low dose aspirin is widelybused for the prevention of cardiovascular events but despite its beneficial effects, it can generate more or less serious digestive disorders. the aim of this study was to evaluate endoscopically by the lanza score the gastroduodenallesions in patients on long dose aspirin with upper gastrointestinal bleeding Materials and methods and result: Among 2135 cases of UGB admitted to emergency departments in the same period, 134 cases occured in patients with low dose aspirin average age: 65.3+/- 24.7 years, sex ratio: 2.3 F/ M. At endoscopic examination: bulbar ulcer in 44/134 (32.9%), antral ulcer in 39/134 (29%) and erosive bulbar duodenitis in 29/134 (21.6%). Stages 3 and 4 of the lanza classification were observed in n95/134 (71%). Conclusion: In this work, women over 65 are the most concerned. bulbar and antral ulcers are the most frequent lesions, and stages 3 and 4 are the most frequent of the lanza score.

A Case Series of Endocoil Erosion Through a Duodenal Ulcer with an Active Bleed

Introduction: Refractory upper gastrointestinal bleeding (UGIB) often requires interventional radiology transcatheter arterial embolization (TAE). Endocoil erosion after this procedure is a rare complication, for which endoscopic therapy has yet to be described. Methods: A case series describing endocoil erosion and bleeding from an ischemic duodenal ulcer with two separate means of endoscopic hemostasis. Results Case 1: 77 year-old female presented with hematemesis and prior UGIB from a duodenal ulcer requiring TAE. Repeated upper endoscopy demonstrated endocoil erosion, with bleeding from a separate inferior visible vessel within an ischemic ulceration in the duodenum. This was successfully treated with epinephrine injection and endoclip placement. Case 2: 52 year-old male presented with epigastric abdominal pain and previous TAE of the gastroduodenal artery (GDA) for refractory bleeding duodenal ulcer. Upper endoscopy demonstrated a posterior duodenal bulb ulcer with an adherent clot and visible endocoil erosion. The prolapsed wire was cut with an endoscopic knot cutter and removed with biopsy forceps in piecemeal fashion. Bleeding was controlled with epinephrine injection and bipolar diathermy. Discussion: Active duodenal hemorrhage can be successfully controlled with TAE to the gastroduodenal artery in instances where endoscopic therapy is unsuccessful. It is important to be aware that the duodenum is supplied by both the superior and inferior pancreaticoduodenal arteries. Despite embolization of one tributary branch, collateral blood flow may still result in bleeding from another arterial branch. Erosion of an endocoil into the gut lumen is a rare complication of TAE. If bleeding ensues, traditional endoscopic therapy with epinephrine, clips, and cautery can be a feasible option in this setting to achieve hemostasis. An endoscopic knot cutter can be used for safe removal of a prolapsed endocoil and facilitate subsequent hemostasis. We report here two similar cases of endocoil erosion into a duodenal ulcer with two different methods of successful endoscopic hemostasis.Figure 1Figure 2Figure 3

Bleeding Duodenal Ulcer Successfully Managed with an Over-the-Scope-Clip

A 70 year-old woman was admitted for right upper quadrant pain with radiation to the back, anorexia and vomiting. Ultrasound abdomen was notable for a dilated CBD to 12mm, thickened gallbladder wall with sludge but no stones and her liver chemistries were normal. HIDA scan and MRCP were also unremarkable. On further inquiry the patient reported 7-month history of abdominal pain and had never previously had an upper endoscopy. The EGD was notable for antral erosions and a pre-pyloric 5mm clean-based ulcer in the stomach. The duodenal bulb was notable for a large 2cm posterior ulcer with large adherent clot with active bleeding (Fig. 1A). The distal duodenum demonstrated no bleeding. The endoscope was removed from the patient and an over-the-scope-clip (OTSC) or “bear claw” was applied to its distal end and the endoscope was reintroduced into the patient's abdomen. Submucosal injection of epinephrine 1:10,000 was made around the lesion with effective mucosal blanching. Then a combination of irrigation and the clear cap was used to remove most of the clot. Then the 12-3 gc OTSC was placed revealing a visible vessel centered within the bear claw (Fig. 1B), effective hemostasis was achieved. A second look EGD three days later and repeat procedure at 4 weeks demonstrated healing of the ulcer (Fig 1C,D). At the last visit an EUS was performed revealing a 10mm CBD with smooth taper to the ampulla, without choledocholithiasis and a 5mm gallbladder polyp. Gastric biopsies for helicobacter pylori were negative. The patient's pain had resolved by that time. The OTSC was designed to ensnare a large amount of tissue to facilitate closure of perforations, fistulas and anastomotic leaks. However, the nitinol made clip has seen its use expand to hemostasis and stent fixation. Posterior duodenal bulb ulcers can present a challenge for the endoscopist. The position may not provide adequate access for management with endoscopic clips or the heater probe. Clips may fall off, injuring the culprit vessel and thereby initiating a cascade of further GI bleeding. In this case, the OTSC easily achieved hemostasis. In addition to acid suppression therapy the OTSC provided adequate ulcer healing in a few days with complete resolution of the duodenal ulcer at 4 weeks. This case demonstrates the expanding role of OTSCs in the gastroenterologist's management of bleeding ulcers.Figure 1

Should endoscopy be routinely performed for bariatric surgery candidates?

Objectives. The rationale for a routine endoscopy before bariatric surgery in asymptomatic patients remains controversial. The purpose of the present study was to compare, in a retrospective manner, the endoscopic findings of morbidly obese patients awaiting surgery with those of non-obese individuals. Methods. Between January 2014 and December 2014, preoperative endoscopic findings of 161 morbidly obese patients and 101 consecutive non-obese individuals were evaluated. Results. No significant differences were found between the two groups in terms of ulcer prevalence and the number of ulcers ( p =0.120 and p =0.122, respectively). However, the frequency of bulbar ulcers was significantly higher in morbidly obese patients than in the non-obese ( p =0.012). Furthermore, the ulcer activity score was significantly higher in morbidly obese patients ( p =0.025). 84 patients underwent laparoscopic sleeve gastrectomy (LSG). Of those, 48 patients (57.1%) had Helicobacter pylori sero-positivity and 12 patients (14.3%) had peptic ulcer disease before surgery. H. pylori sero-positivity persisted in the resected gastric specimens of 33 patients (39.3%). Conclusion. The ulcer activation score in morbidly obese patients is higher -even when they are asymptomatic- than in non-obese individuals. Routine preoperative endoscopy should be considered in all bariatric surgery candidates to rule out pathologies such as hiatal hernia, extensive ulcers or malignant lesions which are the contraindications for a LSG.

The unusual endoscopic finding in a patient presenting with the chronic duodenal bulb ulcer complicated by hemorrhage

The unusual endoscopic finding in a patient presenting with the chronic duodenal bulb ulcer complicated by hemorrhage

Intestinal Neuroendocrine Tumors: The Hidden Hazards

Neuroendocrine tumors (NETs) arise from secretory cells found throughout the body, which makes them biologically & clinically diverse; a diagnostic challenge for both researchers & practitioners. It is not uncommon for them to be diagnosed serendipitously. Two such cases exemplify the abstruse presentations of such tumors. Case 1: A 67 year old male came with abdominal pain & constipation for 5 days. An abdominal CT scan revealed a 1x2 cm necrotic mass adjacent to the uncinate process of pancreas & contiguous with multiple loops of bowel. An endoscopic biopsy with FNA & flow cytometry was non-diagnostic. Patient's symptoms improved with laxative use until 4 months later, when constipation returned. Repeat abdominal CT scan revealed that the mass had increased in size to 7x4 cm, with two new paraaortic lymph nodes. An exploratory laparoscopy was performed where only a partial resection was possible. Histology showed a low grade NET of gastrointestinal tract origin. Patient is currently undergoing octreotide therapy. Case 2: A 60 year old male with hypertension presented after having 3 episodes of bright red blood per rectum for 1 day. He continued to have multiple bleeding episodes in the ED, requiring resuscitation with 11 units of packed RBCs. An upper endoscopy showed a 3 cm clean based duodenal bulb ulcer with no signs of active bleeding. A bleeding scan revealed bleeding at the hepatic flexure & an emergent right hemi-colectomy was performed. During the procedure, liver was notable for multiple small lesions. A biopsy confirmed a low grade NET. Remarkably, the colonic specimen was completely normal. An octreotide scan done later showed increased radiotracer uptake in the mid transverse-colon, presumably the site of bleeding.Figure 1Figure 2Figure 3Discussion: Annual incidence of gastroenteropancreatic NETs in the US is 3.65/100,000 people, making it extremely rare. Patients with NETs may or may not have symptoms attributable to hormonal secretion posing a formidable diagnostic challenge. Revisiting our first patient's prior CT scans, it was found that the size of the tumor had been stable at 8 cm. Carcinoid tumors are highly vascular & can appear iso-dense with liver & pancreas on conventional CT scans, leading to diagnostic errors. Serum chromogranin A along with radiolabeled somatostatin receptor scintigraphy can be extremely useful to visualize non-functioning tumors. Patients with non-metastatic tumors should be treated with resection of the involved segment & small bowel mesentery. Somatostatin analogues & the molecularly targeted agents everolimus & sunitinib improve progression-free survival duration relative to supportive care alone in patients with metastases from a non-functioning pancreatic NET.

The Over-The-Scope-Clip Device: An Indispensable Tool in Interventional Endoscopy: A Case Series

The Over-The-Scope Clip (OTSC) is a novel endoscopic clipping device designed for tissue approximation. It offers an effective endoscopic approach for fistula closure, luminal perforation, GI bleeding, and resection of intra-diverticular colon polyps. We report successful use of this device in a variety of challenging endoscopic scenarios (Figure 1).Figure 1Cases: 1) 53M with history of (h/o) prior feeding tube, presented with (p/w) a non-healing gastro-cutaneous fistula that was successfully closed using one OTSC. 2) 64M with h/o of PUD s/p Billroth II and chronic pancreatitis underwent ERCP with stent placement for CBD stricture. He presented 6 weeks later with perforation of the lateral duodenal wall by the stent. The stent was removed and the perforation was successfully closed using one OTSC device. 3) 67M with h/o cirrhosis p/w a massive GI bleed. Evaluation with EGD and angiogram x2 failed to reveal a source. Push enteroscopy showed an actively bleeding duodenal varix. Ethanolamine injection and band ligation were ineffective. Deployment of the OTSC over the varix resulted in complete and immediate hemostasis. 4) 49M p/w hematemesis. EGD revealed a 2cm duodenal bulb ulcer with a large (>2mm) vessel. Attempts to treat the vessel using standard hemostasis techniques were unsuccessful. One OTSC was deployed over the bleeding vessel with successful hemostasis. 5) 63F with colo-vaginal fistula secondary to Crohn's disease was referred for endoscopic closure. One OTSC device successfully closed the fistula. Discussion/Conclusions: The OTSC device is an excellent tool for treating GI tract hemorrhage, small perforations, and post-op fistulae. While evidence in management of various conditions mentioned above is accumulating, large-scale head-to-head studies are lacking. Further studies are necessary, but the OTSC device represents a valuable tool for high-risk patients that are poor surgical candidates. We describe a case series of patients in which the OTSC device was used for a variety of challenging indications in endoscopic practice.

Mechanical Lithotripsy: A Viable Modality for Endoscopic Gallstone Extraction in Bouveret Syndrome

Introduction: The creation of a bilioenteric fistula is a very rare complication of cholelithiasis which affects less than 1% of patients. The passage of a large gallstone through a cholecystoduodenal fistula and the subsequent impaction in the duodenum causing gastric outlet obstruction, also known as Bouveret Syndrome, is an even rarer occurrence. Given the relatively high mortality of 12-33%, and risk of stone migration causing mechanical small bowel obstruction or other morbidities as high 60%, it is important to diagnose it early and remove the stone safely. This can be done endoscopically, especially in patients who may otherwise be high risk for invasive procedures. Case: Our patient was an 86 year old male patient with a past medical history significant for coronary artery disease and stage 3 colorectal cancer status post resection and chemo -radiation, presented from an outlying facility for intractable sharp abdominal worse postprandially, one week in duration, associated with early satiety, anorexia and 5lbs weight loss in one week. A CT at the outlying facility showed possible choledochoenteric fistula, and a distended stomach. An esophagogastroduodenoscopy (EGD) was performed revealing a large 2.5 - 3 cm stone lodged in the duodenal bulb. The stone was extracted in 2 pieces after mechanical lithotripsy was performed. The duodenum was then reexamined and a posterior wall duodenal bulb ulcer and fistula tract orifice was noted. Examination of the CBD using endoscopic ultrasound pneumobilia. Conclusion: Endoscopic management of Bouveret syndrome is can immediately help in alleviating the gastrointestinal symptoms suffered by patients. Mechanical lithotripsy is one of a number of endoscopic options that can be utilized, especially in stones that are otherwise too large for extraction.Figure 1Figure 2

Predictive Factors of Surgery in Peptic Stenosis of the Bulb

The bulb ulcer stenosis, becoming exceptional in developed countries, remains frequent in our country despite the use of the antisecretory. The purpose of our study was to study epidemiological, diagnostic, and evolutionary complication particularities, and to find potential predictive factors of resistance of ulcer stenosis of the bulb to the pump inhibitors Proton through a recent series. This is a retrospective and descriptive study involving 105 patients, treated for ulcer stenosis of the bulb between January 2007 and December 2012. All our patients had received inhibitors of Proton pump, parenterally for 7 days. They were divided into 2 groups according to their response to treatment: the first group (G1) was sensitive and the second (G2) was resistant. All patients of the G2 were operated. We had compared the two groups. There was no statistically significant difference concerning age, sex, blood group and smoking between the two groups. In univariate study, the age of the epigastralgies was greater than or equal to 9 years; the clapotage fasting, dilation and gastric atony, objectified by the oesogastroduodenal transit were significantly associated with the failure of medical treatment. Only gastric atony and seniority of the disease over 9 years were independent risk factors of resistance to the Proton pump inhibitors in multivariate study.

A Case of Esophagitis Dissecans Superficialis With Concomitant Bullous Pemphgoid

Introduction: Esophagitis dissecans superficialis is an exceedingly rare endoscopic finding characterized by sloughing of large fragments of the esophageal mucosal lining that has uncommonly been associated with autoimmune bullous dermatoses. We report a case of a 77-year-old male who presented with 2 months of upper and lower extremity bullous skin eruptions in addition to more recent odynophagia and melenic stools in the setting of ibuprofen use for analgesia. A diagnosis of bullous pemphgoid was confirmed by direct immunofluorescence which identified immunoglobulin G and complement 3 deposits at the dermoepidermal junction. Endoscopy performed the following day revealed, in addition to a 2 centimeter duodenal bulb ulcer, vertical linear fissures with sloughing of the superficial esophageal mucosa consistent with esophagitis dissecans superficialis. The patient was initially treated with intravenous methylprednisolone for 3 days, followed by a prednisone taper with improvement in his bullous skin lesions, odynophagia and melenic stools. With less than 10 cases of esophagitis dissecans superficialis associated with bullous pemphigoid described in the English literature, prompt endoscopic recognition is vital in corroborating a diagnosis and guiding therapy.Figure 1: Sloughing of large fragments of the esophageal mucosal lining.