Duodenal Bulb Ulcer Research Articles

1884 Migration of Embolization Coil in a Crohn’s Patient With NSAID-Induced Peptic Ulcer Disease

INTRODUCTION: Peptic ulcer-related bleeding has a high mortality rate if not controlled. If endoscopic interventions fail, interventional radiology or surgical intervention is often considered. We report a case of rare complication of Transcatheter Arterial Embolization (TAE) for bleeding duodenal ulcer in a patient with Crohn’s Disease. CASE DESCRIPTION/METHODS: A 69-year-old female with a previous medical history of Crohn's colitis (on prednisone taper for active Crohn’s disease/pending initiation of biologic therapy) presented to the emergency department for generalized weakness, nausea, non-bloody, non-bilious emesis and melena. No prior history of gastrointestinal bleeding, antiplatelet or anticoagulation use was reported. Medications includes: Prednisone 20mg and Naproxen 400mg (BID or TID). Hemoglobin was 6.0 (11.0-16.2 g/dL), BUN 46 (8-26mg/dL), Cr 1.54 (0.44 – 1.00 mg/dL). Upper GI bleed was suspected with the initiation of Pantoprazole 80mg IV, 3 units of pRBC and Intravenous fluids. Endoscopy performed post-resuscitation revealed LA Grade D esophagitis, large non-bleeding duodenal bulb ulcer with extension into the sweep. No endoscopic therapy was performed. Twenty hours later, the patient became hemodynamically unstable requiring massive transfusion. As ulcer was not amenable to endoscopic therapy, Interventional radiology was consulted who TAE with the placement of two coils in the gastroduodenal artery (GDA). The patient tolerated the procedure well without any recurrence of bleeding. A follow-up endoscopy four weeks later, showed improvement in ulceration with only a 3-4 mm area of non-bleeding, healing ulcer with a coil protruding from ulcer site. The coil was left in place without any manipulation to the area. The patient was advised to discontinue NSAIDs and continue Pantoprazole 40 mg BID. In the interim, the patient was started on Vedolizumab (Entyvio) with improvement in CRP and abdominal pain. DISCUSSION: Embolization of GDA is safe and effective in patients with high surgical risk. Complications such as duodenal ischemia, hepatic artery embolization, duodenal stenosis do exist. Migration/Erosion of coil into lumen can occur, especially in a patient with active Crohn’s disease. Ulceration surrounding the coil can occur with a consequence of bleeding, which would require surgical intervention if endoscopic hemostasis is unable to be achieved.

3223 Knot in the Stomach: Metastatic DLBCL Disguised as an Ulcer

INTRODUCTION: Early primary gastrointestinal non-Hodgkin's lymphomas can be difficult to diagnose and can be mistaken for diseases such as Crohn's disease or intestinal tuberculosis. We present a 73-year-old patient who had large duodenal bulb ulcer on endoscopy that resulted in metastatic DLBCL. CASE DESCRIPTION/METHODS: A 73-year-old female with history of osteoporosis, Vitamin B12 deficiency, and leukopenia presented to her primary care physician complaining of feeling knot in upper abdomen for 1 month. She felt the knot was getting progressively bigger with mild abdominal discomfort. She had also complained of early satiety, abdominal bloating, and weight loss of 3-4 pounds in past few months. She denied diarrhea or blood in the stools. Physical exam was significant for minimal distension with prominent palpable pass in right upper abdomen with tenderness to palpation and no lymphadenopathy. Labs showed WBC 4.0, Hb 11.6, Plt 417, Alkaline Phosphatase 235, Alb 3.3. CT scan of abdomen pelvis showed circumferential mass like thickening along gastric antrum, mesenteric implants, and periaortic lymphadenopathy concerning for gastric carcinoma or lymphoma. She was referred to oncologist and gastroenterologist for evaluation with upper endoscopy. EGD showed large duodenal bulb ulcer with necrotic base and small ulcer in antrum. Duodenal biopsy showed newly diagnosed stage IV Diffuse Large B-Cell Lymphoma that also involved gastric, gallbladder, and pancreas. She completed 3 cycles of R-CHOP chemotherapy and was started on high-dose methotrexate for CNS prophylaxis. She had Whipple procedure done after leak of gastrografin and noted to have perforated duodenum. DISCUSSION: Diagnosis of primary GI lymphoma is difficult as it can be nonspecific and often benign gross appearance on endoscopy or colonoscopy. The duodenum represents roughly 6-8% of sites involving small intestine lymphoma. DLBCL of the intestine treated with surgery plus CHOP or R-CHOP chemotherapy has very good prognosis. Early diagnosis and treatment is crucial due to the aggressive nature of this malignancy.

A Case of Acute Esophageal Necrosis in a Patient With Multiple Sclerosis

Introduction: Acute esophageal necrosis (AEN) is a rare syndrome with incidence of .01 to .28% on endoscopic series and mortality of 32%. Known as “Black Esophagus,” it's characterized endoscopically by circumferential black mucosa ending abruptly at the gastroesophageal junction. It has been postulated that precipitating events include hypoperfused states and gastric outlet obstruction with concurrent esophageal reflux. Case: A 77-year-old Caucasian female with remote history of peptic ulcer disease and progressive multiple sclerosis (MS) presented with diffuse abdominal pain, nausea, and vomiting. Urinalysis was suggestive of a urinary tract infection (UTI) and she was discharged on five-days of cephalexin. She delayed taking cephalexin and returned four days later with fatigue, worsening dysphagia, and melena. She was hypotensive and labs revealed leukocytosis, acute blood loss anemia, and acute kidney injury. Urine culture grew extended-spectrum beta lactamase producing multi-drug resistant proteus mirabilis. She was admitted for septic and hypovolemic shock secondary to multi-drug resistant UTI and suspected upper gastrointestinal bleeding. Ertapenem was started in light of the resistance and sensitivity pattern of the causative organism. Upper endoscopy revealed diffuse mucosal changes characterized by black discoloration throughout the esophagus and obstructive duodenal ulcer with adherent clot (Figure 1). Endoscopic findings and presentation was consistent with AEN. She improved with vasopressor support, fluid resuscitation, and 14-days of ertapenem. Discussion: AEN is a multifactorial syndrome with notable morbidity. Risk factors include alcohol abuse, hypertension, male gender, diabetes, dyslipidemia, malnourishment, and chronic kidney disease. The most common presentation is upper GI hemorrhage but dysphagia, chest and epigastric pain can also occur. Diagnosis is made endoscopically and histologic confirmation of tissue necrosis is recommended but not required. Treatment involves management of inciting insult(s), acid suppression with intravenous proton pump inhibitor therapy and “nil per os.” A video swallow study revealed mild oral and moderate pharyngeal dysphagia that was attributed to MS. Dysphagia and regurgitation of stomach contents from gastric outlet obstruction predisposed patient to hypovolemia. Septic shock and an obstructive duodenal ulcer with blood loss anemia culminated to promote the development of AEN.1793 Figure 1. Black discoloration of mucosa in the upper third of the esophagus (A), and the middle third of the esophagus (B), normal mucosa at the gastroesophageal junction as seen in retroflexion (C), and duodenal bulb ulcer (D).

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

Acquired Double Pylorus (ADP): A Rare Complication of Peptic Ulcer Disease

Introduction: Double pylorus (DP) is a rare condition that can be either congenital or acquired. ADP occurs when a peptic ulcer erodes and creates a fistula between the duodenal bulb and the distal stomach. While extremely rare and usually asymptomatic these may occasionally present with abdominal pain or UGIB. Management requires focus on underlying predisposing factors such as PUD or H.pylori. Case: 84 year-old-male with history of CKD, CHF, iron deficiency anemia presented to the ED with complaints of black tarry loose stools and fatigue for a few weeks. He denied any nausea, vomiting or abdominal pain. He also reported constipation and a 20 pound weight loss over the last several months. He also reported a history of gastric ulcer several years ago and colon polyps with last surveillance colonoscopy about 10 years ago. His vital signs were stable and the lab work revealed a hemoglobin and hematocrit of 7.5 g /dl/and 23.2 %. Digital rectal exam revealed an irregular mass in the posterior aspect of the rectum with red blood mixed with black stool. EGD showed a normal stomach along with a DP. Both the channels could be traversed with ease. Two non-bleeding cratered ulcers were seen in the duodenal bulb. Colonoscopy showed a polypoid non-obstructing mass was found in the distal rectum along with black colored blood in the entire colon. Histopathology showed chronic inflammation of gastric mucosa, but negative for H. pylori. Rectal mass, biopsy demonstrated a moderately differentiated adenocarcinoma with extensive necrosis. Patient continued to be on PPI twice daily with no subsequent episodes of melena and was also started on chemoradition for his rectal cancer. Discussion: DP is a rare entity with aprevalence of 0.001%-0.4%. While the congenital variant may be secondary to a gastrointestinal duplication abnormality, ADP is usually a complication of a gastric or duodenal ulcer leading to wall perforation and creation of a fistula. In our patient the etiology was likely acquired due to a prior history of PUD and also the presence of ulcers and inflammation on EGD and biopsy. Systemic diseases like DM that may affect mucosal microcirculation and medications such as NSAIDS and steroids that may impair mucosal healing have been implicated. Medical management usually encompasses acid suppression and testing and treating for H. Pylori, whereas complicated cases may need surgical intervention.2657_A Figure 1. Esophagogastroduodenoscopy shows double pylorus with two patent channels2657_B Figure 2. EGD also showed presence of duodenal bulb ulcer with pigmentation.

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

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.

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.

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

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.

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

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

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.

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.

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

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.