Double-balloon Research Articles

Isolated Jejunal Crohn's Disease: a challenging diagnosis.

A 27-year-old Nepalese male presented with recurrent abdominal pain accompanied by a lower stool consistency over the past 2 years. These episodes occurred several times a year, lasting 1 to 2 weeks, and resolved spontaneously, after adjustment of diet and/or medication for symptomatic control (e.g., antispasmodics, probiotics). Over the last year, the patient had undergone an extensive diagnostic investigation, which revealed no alterations in the laboratory workup, abdominal scan, esophagogastroduodenoscopy, and colonoscopy, including biopsies of the duodenum, and colon, so the symptoms have been attributed to irritable bowel syndrome. However, the symptoms had become more frequent, so the patient was referred to our gastroenterology department. We repeated and extended the work-up. Laboratory investigations showed an elevated erythrocyte sedimentation rate and faecal calprotectin. The remaining laboratory as well an extensive stool workup for infection were unremarkable. Esophagogastroduodenoscopy and ileocolonoscopy were normal. Small bowel capsule endoscopy revealed jejunal mucosa with lymphangiectasias, pseudopolypoids formations and superficial longitudinal ulcers, these findings were corroborated by the double-balloon enteroscopy, and biopsies showed marked architectural distortion, chronic inflammatory infiltrate, and an epithelioid granuloma. The clinical, endoscopic, biochemical, and histological findings were consistent with isolated jejunal Crohn's disease. The patient started adalimumab with complete remission after one year. We present this case given its exuberant endoscopic findings and due to the difficulty in making the diagnosis due to its rarity, location, and unspecific presentation.

Small Bowel Obstruction Caused by Bezoars Treated by Dissolution Therapy with Cola and Crushed by Double-balloon Endoscopy

Small Bowel Obstruction Caused by Bezoars Treated by Dissolution Therapy with Cola and Crushed by Double-balloon Endoscopy

Pain and Satisfaction in Women Induced by Vaginal Dinoprostone, Double Balloon Catheter and Oral Misoprostol

Pain and Satisfaction in Women Induced by Vaginal Dinoprostone, Double Balloon Catheter and Oral Misoprostol

Meckel's diverticulum diagnosed by double-balloon enteroscopy: A single-center retrospective study in Taiwan.

Background and AimMeckel's diverticulum (MD) is a common congenital abnormality of the gastrointestinal (GI) tract. Although a few patients with MD present symptoms, preoperative diagnosis of MD is a clinical challenge because of its endoscopic inaccessibility. The aim of the present study was to investigate patients with MD diagnosed by double‐balloon enteroscopy (DBE) in Taiwan.MethodsWe conducted a retrospective study in a tertiary referral center in middle Taiwan. The clinical characteristics, endoscopic features, histopathological findings, treatment methods, and outcomes of patients with MD diagnosed by DBE were analyzed.ResultsA total of 14 male patients with MD diagnosed by DBE were enrolled. The mean age of all patients was 32.3 years. GI bleeding (78.6%) accounted for the major indication of DBE, followed by abdominal pain and Crohn's disease follow‐up. The mean distance between the ileocecal valve and MD was 68.9 cm. The average length of 12 patients with surgically resected MD was 5.2 cm. The diagnostic yields of the other modalities excepting DBE are as follows: capsule endoscopy, 50%; Meckel's scan, 11.1%; computed tomography, 16.7%; small bowel series, 0%; and angiography, 33.3%. MD presented as a large ostium in 13 patients (92.9%), a small ostium in 1 patient (7.1%), and bleeding signs in 10 patients (71.4%). Twelve patients (85.7%) underwent surgical treatment and 2 patients (14.3%) received conservative treatment. Heterotopic gastric tissue was identified in 4 patients (28.6%).ConclusionThe present study showed that DBE is a more powerful modality in detecting MD than the other conventional modalities in Taiwan.

The Evolution of Device-Assisted Enteroscopy: From Sonde Enteroscopy to Motorized Spiral Enteroscopy.

The introduction of capsule endoscopy in 2001 opened the last “black box” of the gastrointestinal tract enabling complete visualization of the small bowel. Since then, numerous new developments in the field of deep enteroscopy have emerged expanding the diagnostic and therapeutic armamentarium against small bowel diseases. The ability to achieve total enteroscopy and visualize the entire small bowel remains the holy grail in enteroscopy. Our journey in the small bowel started historically with sonde type enteroscopy and ropeway enteroscopy. Currently, double-balloon enteroscopy, single-balloon enteroscopy, and spiral enteroscopy are available in clinical practice. Recently, a novel motorized enteroscope has been described with the potential to shorten procedure time and allow for total enteroscopy in one session. In this review, we will present an overview of the currently available techniques, indications, diagnostic yield, and complications of device-assisted enteroscopy.

Time from Double-Balloon Catheter ejection to oxytocin administration, does it matter?

Induction of labor is attempted in approximately 20% of the deliveries in the western world. The first stage is typically cervical ripening that can be achieved by a double balloon catheter (DBC) followed by oxytocin. We aimed to evaluate whether the time from DBC ejection to oxytocin administration affects the delivery timing and outcomes.

Effective evaluation of two mechanical devices for cervical ripening: Modified double balloon foley catheter versus single balloon foley catheter

Objective: To compare the effective of the modified double balloon Foley catheter (MDB) versus the single balloon foley catheter (SB) on labor induction. Subject and method: This prospective blind trial randomized 80 pregnant women were randomized to MDB group and 80 pregnant women to SB group. Primary outcomes were the rate of cervical ripening success, Bishop score increment, catheter withdrawal time, and cesarean section rate. Result: Cervical ripening success of MDB was 82.5% versus 67.5% of SB with p<0.01. Average Bishop score increment of MDB was 5.63 hour versus 5.02 hour of SB with p=0.033. Cesarean section rate was higher in SB group than MDB group (32.5% and 20.0%, respectively, p=0.048). Conclusion: Using the modified double balloon foley catheter to induce labor is a feasible and effective procedure.

Effective evaluation of labor induction by modifier double balloon Foley catheter at 108 Military Central Hospital

Objective: To evaluate the efficacy of labor induction by modifier double balloon Foley catheter (MDB) in pregnant women with the indication of vaginal delivery. Subject and method: Longitudinal prospective study on 82 pregnant women at Obtetricts Department of 108 Military Central Hospital from June 2020 to September 2021 with criteria: Pregnancy age was older than or equal to 37 weeks, singleton, vertex presentation, their cervical Bishop score < 6, cervix is unfavorable to detach the amnio membranes, intact membranes, to designate termination of pregnancy by vaginal delivery and consent to participate in the study. Labor induction was conducted by double balloon Foley modifier catheter. Result: With success criteria is defined as Bishop score after labor induction larger or equal 7, the success rate with MDB was 86.6%, the increase of Bishop scores averaged 5.63 points with p<0.001. 7.32% tiny fever was connected to Foley catheters. The cesarean section rate after induction was 14.6%. The vaginal birth rate after the succession of labor induction using combined MDBs was 88.7%. There was not any complication for the women and the newborn babies. Conclusion: Our findings suggest that MDB using labor induction was feasible and high effective procedure as well as without compromising maternal or fetal safety.

P032 Clinical Usefulness of Double Balloon Enteroscopy in Patients With Established or Suspected Small Bowel Crohn's Disease.

The diagnosis of isolated small bowel Crohn's disease (CD) can be challenging. Symptoms are non-specific and both imaging and capsule endoscopy (CE) may be misleading as several diseases may mimic CD. Double balloon enteroscopy (DBE) allows a more extensive endoscopic and histologic evaluation of the small bowel. Our aim was to describe the diagnostic utility and impact of DBE on management of patients with known CD and in patients with suspected/rule-out CD. Retrospective review of our institution's DBE database from February 2009 to May 2013. Adult patients referred for DBE for further evaluation of known or suspected CD (due to symptoms, abnormal imaging and/or CE) were included. Patient demographics, clinical characteristics, imaging and CE results, prior DBE, indication for DBE, DBE findings, DBE adverse events, pathology findings, final diagnosis, treatment prior and post DBE and follow-up DBE were abstracted from the electronic medical record. A total of 108 patients were included, 61 (56%) females, mean age 52 years (range 20-83). Indications for DBE included: disease activity assessment/therapeutic in 10 patients with established diagnosis of CD and for diagnostic purposes in 98 patients with suspected CD (31 patients due to abnormal imaging, 29 due to abnormal CE and 26 due to both abnormal imaging and CE). Upper, lower, bidirectional upper and lower, and stomal DBE were performed in 21, 24, 62 and 1 patients, respectively. DBE revealed active disease in 8/10 patients with known CD with one patient undergoing dilation of a stricture. Changes in management were recommended for all patients with active disease - start thiopurine (2), optimize thiopurine dose (1), start biologics (3) change biologics (1), systemic steroids (1) and budesonide (1). The patient who underwent stricture dilation ultimately required surgery. A definitive diagnosis of CD (both endoscopic and histologic) was reached in only 39/98 (40%) patients who were referred for suspected CD. Changes in management were recommended in 32/39 (82%) patients. Interestingly, 24/98 patients had been diagnosed with CD at outside institutions and were recommended to initiate therapy for CD. Of these, CD was confirmed in only 15/24 (63%) patients. Adverse events included perforation in 1 patient (1%) who required surgical management and mouth swelling/abrasion in 3 patients (3%). Follow-up DBE to re-assess disease activity was performed in 10/49 (20%) patients with definitive diagnosis of CD, average time between procedures 4.5 years (range 0.7-11.6). One patient with CD was diagnosed with lymphoma 2.4 years after initial DBE. Changes in management were recommended in 6 patients: de-escalation of therapy (3, two underwent surgery), start thiopurine and/or biologic (2) and switch biologics (1). No complications were seen at follow-up DBE. DBE is a useful technique to confirm a diagnosis in patients who have suspected CD and can help establish a diagnosis of several diseases that may mimic CD on CT scan or CE. Additionally, DBE in patients with established diagnosis of small bowel CD is an effective tool to assess disease activity and guide therapy. Serious complications are infrequent.

Jejunal hemorrhage due to hemolymphangioma successfully detected and controlled by double-balloon enteroscopy.

Lymphangiomas are benign, often subclinical, neoplasms, which can develop in the digestive tracts. Hemorrhagic jejunal tumors are relatively rare and diagnostic challenge. We report herein a case of hemorrhagic jejunal hemolymphangioma successfully diagnosed and treated by double‐balloon enteroscopy.

Endovascular repair of ruptured abdominal aortic aneurysms assisted by double balloon occlusion technique combined with intra-aneurysm fibrin binder injection technique

Objective: To investigate the long-term efficacy and safety of alternating double balloon occlusion combined with intra-aneurysm injection of human fibrin binder in the endovascular repair of ruptured abdominal aortic aneurysm (rAAA). Methods: The clinical data of 28 patients with rAAA admitted to Department of Vascular Surgery, the Fourth Affiliated Hospital of Guangxi Medical University from January 2015 to December 2019 were retrospectively analyzed. There were 23 males and 5 females, aged (62±5) years (range: 46 to 88 years).The maximum diameter of the tumors was (65.2±10.5) mm (range: 47.3 to 100.5 mm), all of which were subrenal rAAA. The intraoperative EVAR for abdominal aortic aneurysm was successfully performed under the emergency green channel procedure, and this surgery was assisted used the double balloon occlusion technique in aorta of inferior renal and superior renalcombined with intraoperative human fibrin binder injection technique. Observation indexes included: patients with preoperative preparation, operation time, hospitalization days, surgical treatment success rate and the incidence of postoperative complications, and aortic stent form during the follow-up period, the incidence of leakage, branch stents patency rate and infection rates. Results: The preoperative preparation time of 28 patients was (45.5±8.5) minutes (range:20 to 100 minutes). The operation time was (100.0±15.5) minutes (range:85 to 210 minutes), the ICU stay time was (7±2) days(range:1 to 17 days). The length of hospitalization was (13.5±2.5) days(range:5 to 43 days). The success rate of surgical treatment was 92.9% (26/28). Two patients died, 1 case died of postoperative multifocal lacunar cerebral infarction and massive gastrointestinal hemorrhage, and another elderly patient (84 years old) died of massive abdominal fluid due to preoperative abdominal aortic aneurysm rupture, postoperative complicated with significant abdominal compartment syndrome, and secondary multiple organ failure. Balloon occlusion of the upper renal aorta took (13±2)minutes (range:12 to 30 minutes). The intraoperative injection of fibrin adhesive was (14±2) ml(range:6 to 28 ml) in 22 cases. The incidence of major postoperative complications was 57.1% (16/28). Among the 26 patients who survived the surgery, 69.2% (18/26) completed the 3-year follow-up, and the follow-up time was (30±3) months(range:13 to 36 months). During the follow-up, the aortic stent was in good shape without obvious displacement. The incidence of leakage within 6 months after the operation was 10.7% (3/28), and there was no internal leakage in the patients who were followed up for 36 months after the operation. The patency rate of renal artery and iliac artery branch stents was 16/18. The incidence of stent infection was 7.7% (2/26), 1 case occurred at 1 month and another case at 6 months, respectively. All patients recovered after prolonged intensive anti-infection therapy. Conclusions: Under the standard emergency treatment process, the double balloon alternating occlusion technique combined with the intra-aneurysm injection of human fibrin adhesive technique can assist the successful completion of the endovascular repair of rAAA, effectively improve the success rate of treatment for patients, and reduce the incidence of postoperative leakage and serious complications. The mid-term and long-term results of EVAR for rAAA are good, safe and reliable.

A Rare Complication of Barium Swallow Test

Question: A 70-year-old man with gastroenteropancreatic neuroendocrine tumor of the duodenum underwent robotic subtotal stomach-preserving pancreatoduodenectomy (PD). During the surgery, retrocolic reconstruction for pancreaticojejunostomy and hepaticojejunostomy, as well as antecolic reconstruction for gastrojejunostomy, were performed. Surgical anatomy following these reconstructions is illustrated in Figure A. The patient’s postoperative follow-up was uneventful. Six months later, the patient underwent a barium swallow test for a medical checkup at another hospital. The examination found no significant findings in the stomach, but revealed reflux of the barium sulfate into the intrahepatic biliary trees through the afferent loop (Figure B). After the barium swallow test on that day, the patient was referred to our hospital. He complained only of fever, but did not demonstrate other symptoms. The laboratory findings showed the following unremarkable changes: white blood cell, 6920/μL; total bilirubin, 0.89 mg/dL; direct bilirubin, 0.25 mg/dL; aspartate transaminase 23 U/L; alanine aminotransferase, 22 U/L; and C-reactive protein, 0.76 mg/dL. The abdominal computed tomography revealed retained barium sulfate in the bilateral biliary system (Figure C). What is the treatment strategy for this patient? Look on page 402 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI. Retained barium sulfate in the biliary system may cause hepatolithiasis because of progressive water absorption, leading to complications such as obstructive jaundice, cholangitis, and sepsis.1Walsham A. Larsen J. Adverse effects of barium sulfate in the biliary tract.Diagn Interv Radiol. 2008; 14: 94-96PubMed Google Scholar Despite the absence of guidelines for the treatment of barium-induced choleliths, evidence-based guidelines for hepatolithiasis after biliary reconstruction propose peroral endoscopic treatment as the first-line option, or percutaneous transhepatic biliary drainage (PTBD) as an alternative.2Tazuma S. Unno M. Igarashi Y. et al.Evidence-based clinical practice guidelines for cholelithiasis 2016.J Gastroenterol. 2017; 52: 276-300Crossref PubMed Scopus (71) Google Scholar However, endoscopic approaches using a double-balloon endoscope (DBE) could be less invasive and have several advantages in bilateral drainage as well as in the accurate evaluation for residual choleliths with peroral direct cholangioscopy.3Ishihara Y. Matsumoto K. Kato H. et al.Treatment outcomes, including risk factors of stone recurrence, for hepatolithiasis using balloon-assisted endoscopy in patients with hepaticojejunostomy (with video).Surg Endosc. 2020; 34: 1895-1902Google Scholar Therefore, urgent endoscopic intervention was attempted in this case. In facilities where DBEs are not available, PTBD should be considered. Using DBE, saline was injected into the biliary trees via a catheter through the hepaticojejunostomy, and barium sulfate lodged at the main bile duct was washed out (Figure D). An endoscopic nasobiliary drainage tube was placed, and further irrigation was conducted for 3 days. After confirmation of duct clearance by a computed tomography scan, the patient was discharged. The reflux of orally administered barium sulfate into the intrahepatic biliary system is a rare but complicated adverse effect of a barium swallow test. To date, several conditions, including spontaneous or postoperative fistula and choledochoenterostomy, have been reported to be associated with reflux.1Walsham A. Larsen J. Adverse effects of barium sulfate in the biliary tract.Diagn Interv Radiol. 2008; 14: 94-96PubMed Google Scholar However, to our knowledge, this report is the first of barium sulfate reflux into the intrahepatic biliary trees in a patient undergoing PD. Urgent endoscopic intervention was safe and effective to prevent barium-induced biliary complications. In conclusion, the present case demonstrated a rare complication of barium sulfate in the biliary system following biliary reconstruction. It suggests that barium swallow test following PD should be contraindicated. Therefore, in similar patients experiencing this rare adverse effect, urgent intervention with DBE or PTBD should be performed to avoid complex biliary complications.

Novel Percutaneous Access to Large Intestine Using a Double Balloon Endolumenal Platform for Tumor Excision: Preclinical Trials and a Case Report

Novel Percutaneous Access to Large Intestine Using a Double Balloon Endolumenal Platform for Tumor Excision: Preclinical Trials and a Case Report

Retrospective comparison of percutaneous balloon pericardiotomy with pericardiocentesis versus pericardiocentesis alone for management of symptomatic pericardial effusions

Abstract Background Cardiac tamponade is a potentially life-threatening complication of pericardial effusion. Pericardiocentesis with drainage is the mainstay of treatment for patients with pericardial effusion and cardiac tamponade. Percutaneous balloon pericardiotomy (PBP) is an adjunct to pericardiocentesis that may alleviate the risk for recurrent effusion and repeat procedures. However, the efficacy of PBP plus pericardiocentesis compared to pericardiocentesis alone is not clear. Purpose We sought to determine whether PBP plus pericardiocentesis was associated with less recurrence of pericardial effusion than pericardiocentesis alone. Methods We conducted a single-centre retrospective analysis of patients ≥18 years old with non-iatrogenic pericardial effusion undergoing either pericardiocentesis alone or PBP plus pericardiocentesis for the first time. For PBP, a balloon was advanced over a guidewire until it crossed the pericardium and was then inflated until the balloon profile was fully expanded. Type of balloon used, and single or double balloon technique were left up to the operator. Recurrent pericardial effusion was defined as a large pericardial effusion on echocardiogram, pericardial effusion that caused hemodynamic compromise, or pericardial effusion that necessitated another intervention to drain at any time after initial procedure. Risk factors for recurrent pericardial effusion were also assessed. Results There were 208 patients who underwent pericardiocentesis, with 33 patients receiving PBP plus pericardiocentesis. In all patients, the rate of recurrent pericardial effusion was 15.9% and 15.2%, respectively (p=0.92). In patients with a cancer diagnosis at time of procedure, the rate of recurrent pericardial effusion was 17.8% and 16.7%, respectively (p=0.89). In patients with malignant pericardial effusion as confirmed by cytology, the rate of recurrent pericardial effusion was 20.4% and 13.3%, respectively (p=0.72). Patients with a connective tissue disease (CTD) had an increased odds ratio (OR) of recurrent pericardial effusion when compared to patients without a CTD (OR 3.19, 95% CI 1.31–7.77). Conclusions The results of this study suggest that PBP plus pericardiocentesis offers no significant benefit over pericardiocentesis alone at preventing recurrent pericardial effusion. This finding was true in all sub-groups, including patients with cancer and patients with malignant pericardial effusion. Patients with a CTD were three times more likely than patients without a CTD of having a recurrent pericardial effusion, independent of treatment strategy. Funding Acknowledgement Type of funding sources: None.

S3375 Utility of Double Balloon Enteroscopy in Patients with Orthotopic Liver Transplant with Hepaticojejunostomy: Observational Study

Introduction: Double Balloon enteroscopy ( DBE ) in patients with altered anatomy can be technically challenging, however offers both diagnostic and therapeutic useful modality. We describe the patients with h/o orthotopic liver transplant with hepatic jejunostomy who underwent DBE with regards to indications, and readmissions Methods: From a large database of patients who underwent DBE, patients with h/o orthotopic liver transplant with hepatic jejunostomy were identified and their charts were reviewed. Results: We found total of 9 DBE procedures performed on 6 patients (males = 5, female = 1). Readmission within 30 days was seen in 2 patients and readmission from 30 days- 6 months was seen in 1 patient and they underwent repeat DBE again. Indications for DBE was biliary strictures (n = 2), GI bleed (n = 2). All the patients were classified as either ASA class 3 (n = 8) or ASA class 4 (n = 1) and underwent general anesthesia. DBE was performed predominantly for indications of pancreatico-biliary interventions requiring ERCP (n = 7) or obscure GI bleeding (n = 2). Positive diagnostic yield was 88 % with major abnormal findings includes strictures with or without CBD dilation (n = 4), anastomotic ulcers (n = 3). Therapeutic yield was noted in 55 % cases and the common therapies utilized were for biliary interventions modalities (n = 5), hemoclipping, epinephrine injections (n = 1) and no intervention performed in 4 patients. No intra-procedural adverse events were noted. Conclusion: DBE in patients with Orthotopic liver transplant with hepaticojejunostomy has a high diagnostic and therapeutic yield. DBE is a useful modality for GI intervention, especially in the patients who underwent such procedures.

S551 Efficacy and Safety of Double- versus Single-Balloon Retrograde Enteroscopy

Introduction: Previous studies have reported conflicting results on the outcomes of double-balloon enteroscopy (DBE) and single-balloon enteroscopy (SBE). We aimed to compare efficacy and safety of DBE to SBE via retrograde approach. Methods: We performed a retrospective analysis of all patients who underwent retrograde DBE or SBE at a large, tertiary referral center from 2008 to 2018. Data was collected on demographics, baseline comorbidities, antiplatelet and anti-coagulation use. Outcomes assessed included technical success, diagnostic yield, therapeutics, depth of insertion and procedural duration. The analysis was done using SPSS software. Results: A total of 523 (403 DBE, 120 SBE) patients underwent retrograde enteroscopy during the study period. The mean age was 59.4 ± 17.24 and 59.57 ± 16.94 in DBE and SBE group, respectively. There was no difference in gender, comorbidities, smoking history, clopidogrel, anti-coagulation use, platelet count, and laboratory parameters between both groups. Aspirin use was significantly higher in DBE group (40.8% vs. 29.9%, P = 0.03) (Table 1). The indication for enteroscopy was obscure gastrointestinal bleeding (OGIB) in 66.5% and 55.8% of DBE and SBE procedures, respectively. There was no difference in technical success (91.0% vs. 92.5%, P = 0.85), diagnostic yield (40.9% vs. 40.8%, P = 0.95) and therapeutics (17.1% vs. 19.1%, P = 0.61) between DBE and SBE. Compared to SBE, DBE had significantly shorter mean procedure time (26.5 ± 34.5 min vs. 34.8 ± 29.4 min, P = 0.01) but higher maximal depth of insertion from ileo-cecal valve (108.1 ± 84.1 cm vs. 73.3 ± 63.4 cm, P = 0.001). In addition, proximal ileum was reached in 22.6% of DBE procedure as compared to 6% in SBE (P < 0.001). On subgroup analysis based on OGIB indication, DBE again had significantly higher depth of insertion (113.1 ± 87.07 cm vs. 79.9 ± 66.5 cm, P = 0.02) and rates of proximal ileum reach (23.7% vs. 7.1%, P = 0.006) as compared to SBE but there was no statistically significant difference in diagnostic yield (34.5% vs. 26.9%, P = 0.23) and therapeutics (20.3% vs. 14.9%, P = 0.31). Safety events were rare and similar in both groups (Table 2). Conclusion: Retrograde DBE is associated with significantly higher depth of insertion and shorter procedural duration but similar diagnostic yield and technical success as compared to.Figure:: Baseline and Demographics factors for both groupsTable 2.: Outcomes comparing DBE and SBE

S1341 Development of a Convolutional Neural Network for the Detection of Vascular Lesions in Double-Balloon Enteroscopy: A Proof-of-Concept Study

S1341 Development of a Convolutional Neural Network for the Detection of Vascular Lesions in Double-Balloon Enteroscopy: A Proof-of-Concept Study

HEMORRHAGIC SHOCK: WHERE IS THE BLEED?

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Meckel diverticulum(MD), characterized as a common congenital malformation and is well studied in the pediatric population but less so in adults. Our case emphasizes MD as one of the possible diagnoses of gastrointestinal bleeding in adults when CT scans and endoscopic evaluations are unremarkable. Also, if the suspicion is high, the technetium 99m pertechnetate is also not often adequate to exclude the diagnosis. CASE PRESENTATION: 28 year old male with a history of Inflammatory bowel syndrome presented to the emergency department with lightheadedness and palpitations. Soon after, he experienced a large melanotic stool and was transferred to the ICU with hypovolemic shock. His labs were notable for normocytic normochromic anemia for which he was transfused with packed red blood cells. CTA abdomen and pelvis demonstrated no evidence for active extravasation. The patient continued to have massive melenic bowel movements requiring repetitive blood transfusion for his hemorrhagic shock. Bedside double endoscopy showed non-bleeding internal hemorrhoids with no obvious source of bleeding. Subsequently, workup was broadened to a tagged RBC scan which was positive in the mid to distal small bowel prompting small ileal branch embolization. However, bleeding persisted for which Meckel's scan was ordered and found to be suggestive of Meckel's diverticulum. Subsequently, he had a laparoscopic small bowel resection which led to the resolution of symptoms. DISCUSSION: Meckel's Diverticulum is a rare entity in adults with only 17 cases reported in literature in the last year. It usually presents in childhood with more than half of the patients being less than 10 years old.MD usually presents with intestinal obstruction, hemorrhage and inflammation ofthe diverticulum with or without perforation. Bleeding usually occurs from an ulcer due to ectopic gastric mucosa producing acid and damaging the intestinal mucosa. Clinical features are comparable to any other inflammatory condition and can be confused with more prevalent conditions like acute appendicitis. Meckel's nuclear scan proves to be the standard test in case of high suspicion with a sensitivity of 89.6% and specificity of 97.1%. Other testing modalities include X-ray, CT scan or an MRI in case of an obstruction. Mesenteric arteriography in case of GI bleeding, double-balloon enteroscopy or capsule endoscopy can be used in order to directly visualize the MD, or abdominal exploration can be done as required if the diagnosis remains unclear with high index of suspicion.The standard of treatment in case of a symptomatic patient is surgical resection by performing a diverticulectomy that our patient underwent and was discharged to medical floor after stabilization. CONCLUSIONS: Meckel's Diverticulum remains a diagnosis associated with pediatric population although should not be forgotten in cases of adults with unexplained gastrointestinal bleeding. REFERENCE #1: Lequet J, Menahem B, Alves A, Fohlen A, Mulliri A. Meckel's diverticulum in the adult. J Visc Surg. (2017) 154:253–9. 10.1016/j.jviscsurg.2017.06.006 [PubMed] [CrossRef] [Google Scholar] REFERENCE #2: Choi SY, Hong SS, Park HJ, Lee HK, Shin HC, Choi GC. The many faces of Meckel's diverticulum and its complications. J Med Imaging Radiat Oncol. (2017) 61:225–31. 10.1111/1754-9485.12505 [PubMed] [CrossRef] [Google Scholar] REFERENCE #3: Stone PA, Hofeldt MJ, Campbell JE, et al. Meckel diverticulum: ten-year experience in adults. South Med J 2004;97:1038-41. [PubMed] DISCLOSURES: No relevant relationships by Imama Ahmad, source=Web Response No relevant relationships by Anneris Estevez, source=Web Response No relevant relationships by Sneha Lakshman, source=Web Response

S1358 Automatic Detection of Small Bowel Ulcers and Erosions in Double-Balloon Enteroscopy Using a Convolutional Neural Network: A Proof-of-Concept Study

S1358 Automatic Detection of Small Bowel Ulcers and Erosions in Double-Balloon Enteroscopy Using a Convolutional Neural Network: A Proof-of-Concept Study

S2515 Where Did You Come From, Where Did You Go? A Tall Tale of Bouveret’s Travels

Introduction: Bouveret syndrome (BS) refers to a gastric outlet obstruction (GOO) secondary to an impacted gallstone in the pylorus or proximal duodenum. Our case describes BS with migrated gallstone to the distal jejunum causing a small bowel obstruction (SBO) successfully treated with prompt interventional endoscopic (IE) intervention. Case Description/Methods: 86-year-old male presented with nausea, vomiting, and hiccups for the past 3weeks. CT revealed dilated stomach, possible GOO. Urgent endoscopy revealed dilated stomach, 1 large completely obstructing, non-bleeding cratered duodenal ulcer, and large impacted gallstone at the distal duodenal bulb. IE consultation prompted repeat EGD 3 days later showed 1cm fistula in the duodenal bulb to the gallbladder remnant, no evidence of residual gallstone in the bulb, second and third portion of duodenum were normal. CT showed SBO with a transition point in left hemiabdomen. Subsequent double-balloon enteroscopy identified 4cm gallstone in distal jejunum causing SBO. Electrohydraulic lithotripsy successfully fragmented the stone (Figure 1). Patient advanced diet and fully recovered. Discussion: Bouveret's syndrome, described in 1770, represents 2–3% of all gallstone-related GOO and 1–4% of all SBOs. Morbidity and mortality rates, about 60% and 30% respectively, are reported in cases where a patient is a nonsurgical candidate due to comorbidities. Large stones typically require surgical intervention and have high mortality (12-27%). Our case describes treatment success with IE.Figure 1.: First EGD: A, severe LA Grade D esophagitis, B-H shows large completely obstructing, non-bleeding cratered duodenal ulcer 30mm, and large gallstone impacted at the distal end of duodenal bulb. Second EGD: I-K Duodenal Fistula, L-N Fistulous connection to Gallbladder Double Balloon Enteroscopy: O, Large impacted gallstone in distal jejunum. P-U electrohydraulic lithotrpsy performed on impacted gallstone, U-V Clearance of broken particles with aggressive flushing, W-Y Fluoroscopic images showing radiolucent defect, Z Resolution of defect on fluoroscopy.