Annular Pancreas Research Articles

Bile Stained Vomiting in Neonates: Radiological and Surgical Correlation

Abstract Background: Bile stained vomiting in neonates is fre-quently encountered clinical symptom in pediatric practice. It is very important to examine them and exclude or confirm surgical condition. Aim of Study: This work is advocated to illustrate the spectrum of radiological findings in neonates with bile stained vomiting and correlate them with surgical data. Patients and Methods: All included neonates presented with bile stained vomiting were referred to Diagnostic Radi-ology Department at Sohag University Hospitals. Abdominal X-ray, abdominal ultrasound, Doppler and contrast imaging were done to identify the surgical causes of bilious vomiting with clinical and surgical correlation. The patients were treated surgically in Pediatric Surgery Unit at Sohag University Hospitals. Patients with bilious vomiting caused by non-surgical causes were excluded. Results: Our study included 31 bile stained vomiting neonates with age range from one day to 30 days and with male sex predominance (17 boys and 14 girls). Four patients were found to have necrotizing enterocolitis, 5 cases with mid-gut volvulus, 3 cases were found to have distal duodenal atresia, one case with duodenal stenosis, 5 cases with jejunal atresia, 4 cases with ileal atresia, 2 cases with congenital bands, 2 cases with complicated congenital inguinal hernias, 2 cases with meconium plug, 1 case with neonatal intussus-ception, 1 case with iatrogenic clamping of umbilical hernia and 1 case with anal stenosis. Imaging techniques were diagnostic in most of the cases and correlate with surgical findings. Conclusion: Bile stained vomiting in the newborn usually indicative of surgical conditions and needs surgical consulta-tion. Imaging studies are of utmost important to investigate and diagnose these cases before surgery.

A109 CELIAC DISEASE IS A RARE CAUSE OF BENIGN DUODENAL STRICTURE

Abstract Background Benign duodenal stricture is an uncommon problem encountered by gastroenterologists. The most common cause is peptic ulcer disease (PUD). With the diagnosis and eradication of H. Pylori, early diagnosis of PUD and the use of PPIs to treat upper gastrointestinal inflammation, the incidence of benign duodenal stricture has dramatically decreased. Patients with duodenal stricture may present with early satiety, nausea, vomiting and weight loss. We present the case of a man with a refractory web-like stricture in the second part of the duodenum (D2) caused by Celiac disease. Aims To describe a rare endoscopic finding in a patient with Celiac disease Methods Case report with literature review Results We present a case of a 64 year old male was referred for consideration of duodenal stenting of a refractory stricture in the second part of the duodenum D2. The patient had a 1 year history of abdominal pain, early satiety and weight loss (10 lbs). He also reported intermittent episodes of diarrhea. Investigations included a CT scan of the abdomen which showed a stricture at the level of proximal D2 described as a “duodenal band”. Previous attempts at balloon dilation had not resulted in prolonged symptomatic or endoscopic improvement. Testing for H. Pylori was negative and he did not use NSAIDs. Upper endoscopy was performed to assess the stricture prior to consideration of stenting. This showed a tight web-like stricture in proximal D2. The stricture was balloon dilated up to 16.5 mm, enabling the endoscope to pass beyond it. The mucosa in D2 was atrophic with flattening of the folds and scalloping. There was no inflammation seen. Biopsies from D2 revealed moderate villous blunting and intraepithelial lymphocytosis. Celiac serology testing was abnormal, with an anti-tTG Ab level of 32 RU/ml which confirmed the diagnosis of Celiac disease. The balloon dilation and gluten-free diet resulted in resolution of his symptoms. Follow up endoscopy revealed normalization of his duodenal folds and biopsies. In addition, anti-tTG Ab level was normalized. Although stricture improved with prolonged patency, he still has mild recurrence of his stricture requiring balloon dilation on an annual basis. Conclusions This case describes a very uncommon complication of Celiac disease. The likely pathophysiology involves inflammation and potentially ulceration from Celiac disease, resulting in a benign stricture. There have been a few case reports describing duodenal strictures as a complication of Celiac disease. Treatment involves a gluten-free diet and endoscopic therapy. More severe cases of obstruction would likely require surgical intervention. In our case, the gluten-free diet and balloon dilation were successful and duodenal stenting was not necessary. Given the possibility of Celiac disease as a cause of duodenal stricture, it would be reasonable to biopsy D2 and check anti-tTG Ab in cases of duodenal stricture. Funding Agencies None

EUS-guided choledochoduodenostomy by use of electrocautery-enhanced lumen-apposing metal stents: a French multicenter study after implementation of the technique (with video)

EUS-guided biliary drainage is indicated in cases of impossibility or failure of classic biliary drainage by ERCP. Recently we reported good efficiency of EUS-guided choledochoduodenostomy (EUS-CDS) using the electrocautery-enhanced lumen-apposing metal stent (ECE-LAMS) in a retrospective multicenter study. Use of the recommended technique (direct puncture with the ECE-LAMS with use of a pure cut current and a 6-mm stent) was the only predictive factor of clinical success. We re-evaluated this procedure after 1 year in the same centers. This was a French retrospective multicenter study of a prospective database including all cases of EUS-guided CDS with ECE-LAMS in the 7 centers that participated in the first study. Seventy consecutive patients were included in this study between September 1, 2017, and September 22, 2018. Failure of primary ERCP was due to duodenal stenosis in 44% of cases and to tumoral infiltration of the papilla in 22% of cases. The mean duration of the procedure was 5 ± 3 minutes. The recommended technique was used in 98.5% of cases. The technical and clinical success rates were both 97.1% (69/70). Short-term adverse events (periprocedural and intrahospital) occurred in 1.6%. EUS-CDS with the ECE-LAMS is efficacious and safe in distal malignant obstruction of the common bile duct in cases of ERCP failure with impressive results once expertise is acquired and the recommended technique (direct fistulotomy, pure cut current, and 6-mm stent) is followed.

Laparoscopic Roux-en Y duodenojejunostomy: A safe and physiological treatment for symptomatic annular pancreas in adults.

Background:Annular pancreas is a rare, congenital, rotational anomaly of pancreas, seen usually in newborns who present with features of duodenal obstruction. However, in adults, only 24% of cases are present with duodenal obstruction. Surgery remains the procedure of choice in patients in whom symptoms can be attributed to duodenal obstruction and the goal of surgery is to relieve obstruction by bypassing the annulus. Laparoscopic Roux-en Y duodenostomy (DJ) is our preferred bypass approach for this condition. Literature search revealed that very few case reports have been published about laparoscopic management of annular pancreas, especially about duodenojejunal anastomosis. We present our experience in the laparoscopic management of symptomatic annular pancreas in adults and technique of the laparoscopic Roux-en Y DJ for annular pancreas.Materials and Methods:Between 1996 and 2016, a total of six adult patients underwent laparoscopic management for symptomatic annular pancreas. The demographic, perioperative and follow-up details were documented.Results:All surgeries were successfully performed by laparoscopic approach with no conversion to open. Five cases underwent Roux-en Y DJ and one underwent gastrojejunostomy. No major perioperative events occurred. The mean length of hospital stay was 5.6 days. Five out of six patients were followed up for 24 months, and no symptom recurrence was seen.Conclusion:Laparoscopic Roux-en Y duodenojejunostomy could be used as a safe and physiological treatment for annular pancreas in adult patients and should be preferred for the treatment of duodenal obstruction due to annular pancreas.

Exploring the neglected segment of the intestine: the duodenum and its pathologies.

Herein we reviewed the computed tomography (CT) findings of a spectrum of pathological entities affecting the duodenum. We discuss the CT findings of some congenital, inflammatory, traumatic, and neoplastic pathologies of the duodenum along with the conventional barium studies of selected conditions. Pathologies of this C-shaped intestinal segment, derived from both foregut and midgut, are often overlooked in clinical practice and radiological literature. While congenital anomalies like duplication cysts and diverticula are usually asymptomatic, annular pancreas and malrotation may manifest in the first decade of life. Primary as well as secondary involvement of the duodenum by various disease processes can be evaluated by careful CT technique and proper attention to the duodenum. Among congenital conditions, annular pancreas, duplication cyst, superior mesenteric artery syndrome, midgut volvulus, and diverticula are presented. Duodenal involvement in adenocarcinoma, lymphoma, gastrointestinal stromal tumours, Crohn’s disease, and groove pancreatitis are discussed. Duodenal wall haematoma and traumatic duodenal perforation causing pneumoretroperitoneum in two patients after blunt trauma of the abdomen are also illustrated. CT provides superb anatomic detail and offers high diagnostic specificity for the detection of duodenal pathologies because it allows direct imaging of the intestinal wall, secondary signs of bowel disease within the surrounding mesentery, and abnormal findings in adjacent structures. Primary duodenal malignancies and local extension from adjacent malignancies can be diagnosed by CT reliably. CT also plays a vital role in the diagnosis of traumatic duodenal injury by differentiating between mural haematoma and a duodenal perforation because the latter requires immediate surgical intervention.

Rare Neonatal Digestive Surgical Emergencies at the Brazzaville University Hospital Center

The purpose of our study was to evaluate the morbidity-morality of rare neonatal digestive emergencies in order to improve their management. Observations: 7 newborns ranging in age from 6 hours to 3 weeks were treated for rare digestive pathologies between January 2013 and July 2017 (a period of 3 years and 6 months) in the Department of Pediatric surgery of Brazzaville University Center, Congo. Males were predominant (5 versus 2 females). Pathologies listed were: 1 antenatal volvulus of the small intestine, 1 annular pancreas and 5 gastric perforations. The average time of care in the operating room was 12 hours. The newborns were hospitalized in the pediatric surgery department in 28.6% of cases (n = 2), and 71.4% (n = 5) in the neonatology department. The antenatal volvulus of the intestine and annulus pancreas were integrated into a nosologic entity named neonatal occlusion (NNO). The postoperative outcomes were simple for 4 patients (57.14%) while 3 patients died immediately after surgery (42.86%). Conclusion: Neonatal surgical emergencies are still difficult to manage in our context. The lack of knowledge of these rare pathologies, which delays their management, considerably increases morbidity-mortality. The critical analysis of this series highlights diagnostic and therapeutic difficulties particularly with gastric perforations, hence the interest of better popularization of pediatric surgery.

Variation in reporting of the Frey pancreatico-jejunostomy: Current world experience

Introduction: In 1987 Frey and Smith described their operation for chronic pancreatitis which involved an extended lateral pancreaticojejunostomy combined with removal by coring of the parenchyma in the anterior aspect of the head of the gland. The Frey pancreaticojejunostomy has now been reported from centres across the world. However, unlike more clearly defined procedures such as pancreatoduodenectomy, there is no standardization of the Frey operation resulting in potential heterogeneity. This study is an overview of the current world experience of the Frey operation with emphasis on variance in reporting. Methods: A search of the literature was performed using the Scopus database for publications between 1st January 1970 and January 2018. The keyword and MESH heading “chronic pancreatitis”, was used together with the term “Frey Pancreaticojejunostomy”. The risk of bias was assessed using the Cochrane collaboration’s tool for assessing risk of bias in non-randomized studies of interventions. The protocol was reviewed by the research and development department of Central Manchester University Hospitals NHS Foundation Trust. There were 34 reports of the Frey pancreaticojejunostomy and these constitute the study population Results: Data are affected by selection bias and reporting bias. In terms of assessing the morphology of the gland being operated, maximum antero-posterior diameter of the main pancreatic duct was reported in 19 (56%) of reports, antero-posterior diameter of pancreatic head in 13 (38%). Portal vein patency was confirmed in 4 (12%). The presence or absence of a concomitant biliary stricture was reported in 22 (65%) and a duodenal stricture in 14 (41%). Conclusion: The Results demonstrate that there is substantial variation between centres in reporting of the Frey operation. This variance compromises the value of comparative outcomes of this procedure and highlights the need for better standardization of the reporting of outcomes of surgery for chronic pancreatitis.

Minimally Invasive Surgery for Congenital Abdominal Cystic Lesions in Newborns and Infants.

In the variety of congenital abdominal cystic lesions (CACL) of different origin, ovarian cyst is the most common intra-abdominal pathology in female neonates. The prognosis and timing of treatment varies depending on the nature of CACL. This study aimed to assess the results of diagnostics and treatment of CACL. A retrospective analysis was performed of 39 cases of CACL, with the spectrum including ovarian, enteric, mesenteric and pancreatic origin. Outcome of minimally invasive surgery, open surgery or conservative approach was analyzed. Twenty-eight neonates underwent surgery, while 11 were treated conservatively. Twenty patients were treated with a laparoscopic technique and eight with laparotomy combined with laparoscopy. Final diagnosis included: Fifteen cases of ovarian pathology (ovarian torsion in 11 cases), 12 treated laparoscopically and three with laparotomy, six enteric duplications (four laparoscopic and two laparotomic), three mesenteric cysts (one laparoscopic and two laparotomic), two pancreatic cysts (both laparoscopic only), two duodenal stenoses, including duodenal septum (both laparotomies with Heineke-Mikulicz plasty). No blood transfusion apart from two cases requiring re-laparotomy and no early complications were observed in any case; no death occurred. With the strategy of management based on ultrasound and laboratory data, a laparoscopically assisted minimal access approach resulted in minimal risk of complications and complete recovery in all patients, leading to exclusion of oncological risk.

Endoscopic management of local complications of chronic pancreatitis.

Endoscopic treatment of local complications in patients with chronic pancreatitis has gained ground over the surgical alternative in the last few years. The lower aggressiveness of endoscopic treatment, as well as the possibility to use it repeatedly in high-risk patients, has favored this development. In addition, the incorporation of new, highly accurate endoscopic therapeutic options such as pancreatoscopy-guided lithotripsy and endoscopic ultrasound-guided treatments make endoscopic treatment the first choice in many cases, despite discordant data in the literature. This article reviews the endoscopic treatment of the most common local complications of chronic pancreatitis, such as pancreatolithiasis, pseudocysts, and pancreatic, biliary, and duodenal ductal stenosis.

Stage IV Breast Cancer with Duodenal and Ureteral Stenosis due to Retroperitoneal Metastasis—A Case Report—

症例は49歳，女性．来院8カ月前より左乳房腫瘤を自覚するも未受診．頻回の嘔吐を主訴に来院し，精査にて皮膚浸潤をきたす左浸潤性乳癌（luminal B type）・左腋窩リンパ節転移，十二指腸狭窄・右尿管狭窄を認めた．鑑別として乳癌stage IV（腹腔内・後腹膜転移），重複癌（乳癌+腹腔内原発癌），進行乳癌と後腹膜線維症との合併などが考えられた．各種検査・検討するも確定診断に至らず，消化器外科にて十二指腸狭窄解除および診断目的に開腹手術を行った．後腹膜・結腸間膜に播種病変を認め，さらに十二指腸と右尿管を圧迫する硬く一塊となった後腹膜腫瘤を認めた．根治切除は困難と判断しバイパス術を施行した．播種病変の病理検査にて，乳癌の腹腔内・後腹膜転移と診断した．食事摂取可能となり栄養状態が改善された後に，乳癌stage IVに対する全身薬物療法を行い，10カ月経過しPRを維持している．

A Case Report of Xanthogranulomatous Cholecystitis with a Duodenal Ulcer and Stenosis Mimicking Gallbladder Carcinoma

A Case Report of Xanthogranulomatous Cholecystitis with a Duodenal Ulcer and Stenosis Mimicking Gallbladder Carcinoma

СОЧЕТАНИЕ ПЕНЕТРАЦИИ И ПИЛОРОДУОДЕНАЛЬНОГО СТЕНОЗА ПРИ ЯЗВЕННОЙ БОЛЕЗНИ ДВЕНАДЦАТИПЕРСТНОЙ КИШКИ

The review provides an analysis of the literary data devoted to the problem of surgical treatment of duodenal stenosis combined with ulcer penetration. Still in the scientific literature has an ambiguous interpretation of the concept of ulcer penetration: it also exceptionally includes the presence of a large ulcerative crater penetrating into a neighbouring organ with periulcerous inflammatory infiltrate. Hereby, cicatricial adhesions with neighboring organs, as the result of preceded ulcer penetration, are not considered penetration. There are controversial views among the surgeons regarding surgical tactics, volume and surgical technique. The particular situation in surgery of duodenal ulcer is domination of resection methods over organsaving techniques. There’s a wrong opinion of impossibility of organ-saving surgery in penetrating duodenal ulcer. In recent years, the methods of low-invasive surgery have become increasingly popular. The analysis of literary data shows that there is insufficient knowledge of this problem, the debatability of a number of issues requiring their final solution.

Incidental Finding of Annular Pancreas in a Routine Cadaveric Dissection: Case Report

AbstractAnnular pancreas is a rare congenital anomaly that results from the malrotation of the ventral pancreatic bud. The presentation of annular pancreas varies: it can be asymptomatic or present clinical symptoms of duodenal obstruction that can affect all age groups, from newborns to adults. In the present case report, we describe a complete type of annular pancreas at the level of the second part of the duodenum, which was an incidental finding in a prosected specimen. This anomaly has significant clinical relevance to clinicians and radiologists due to its variable presentation. The embryological, clinical and radiological aspects of this congenital anomaly are discussed in detail in the present article.

The experience of surgical treatment of small bowel atresia

Purpose of the study was to improve the surgical treatment results of intestinal tract congenital anomalies. Materials and methods. 31 children with small bowel atresia were treated in our department by 2014–2019. This group of patients was performed by as neonates, as 2-years old children. There were 17 boys. There was no mortality. Morphologically this group was consisted of 8 cases of duodenal web, 1 case of annular pancreas, 10 cases of duodenal atresia. Jejunoileal atresia were found in 12 cases and in 7 cases it was combined with perforation, which in 5 cases was antenatal. Results and discussion . In case with duodenal web it was incised. In 10 patients with duodenal atresia and annular pancreas diamond-shaped anastomosis was performed and in one case side-to-side duodenojejunoanastomosis was created. In patients with jejunoileal atresia the resection and primary anastomosis was performed in 3 cases, Bishop-Koop anastomosis was created in 5 cases and in 4 patients temporary enterostomy with subsequent anastomosis creation in 2 months was performed. Multiple type of atresia, cases with perforation and evident disproportion of proximal and distal segments were criterion for two-step surgical method choosing. Conclusions . According to our experience if multiple type atresia and evident disproportion of proximal and distal segments is present, the surgical treatment should be performed by Bishop-Koop anastomosis creation.

Sufu- and Spop-mediated downregulation of Hedgehog signaling promotes beta cell differentiation through organ-specific niche signals

Human embryonic stem cell-derived beta cells offer a promising cell-based therapy for diabetes. However, efficient stem cell to beta cell differentiation has proven difficult, possibly due to the lack of cross-talk with the appropriate mesenchymal niche. To define organ-specific niche signals, we isolated pancreatic and gastrointestinal stromal cells, and analyzed their gene expression during development. Our genetic studies reveal the importance of tightly regulated Hedgehog signaling in the pancreatic mesenchyme: inactivation of mesenchymal signaling leads to annular pancreas, whereas stroma-specific activation of signaling via loss of Hedgehog regulators, Sufu and Spop, impairs pancreatic growth and beta cell genesis. Genetic rescue and transcriptome analyses show that these Sufu and Spop knockout defects occur through Gli2-mediated activation of gastrointestinal stromal signals such as Wnt ligands. Importantly, inhibition of Wnt signaling in organoid and human stem cell cultures significantly promotes insulin-producing cell generation, altogether revealing the requirement for organ-specific regulation of stromal niche signals.

1330 Recurrent Abdominal Pain in the Elderly: An Interesting Case of SBO and Brittle Diabetes Due to Undiagnosed Annular Pancreas

INTRODUCTION: Annular pancreas, a congenital anomaly caused by a complete or partial ring of pancreatic tissue surrounding the descending duodenum, is uncommon and often presents in childhood with gastric outlet obstruction. Although the incidence is 5-15 per 100,000 patients based on autopsy, the true incidence rate is unknown as many patients are asymptomatic. We present a case of recurrent abdominal pain and associated uncontrolled Diabetes and undiagnosed annular pancreas. CASE DESCRIPTION/METHODS: An 83-year-old female with a history of CAD, DM2, HTN, HLD, GERD, and recurrent abdominal pain with labile diabetes presented to the ED with abdominal pain for 2 days. The pain was epigastric and associated with constipation and inability to pass flatus for 1 day. Labs were significant for glucose of 529, ALP of 204, AST of 96, ALT of 108, lactate of 2.6, and HbA1c of 16.6. She underwent CT Abdomen/Pelvis, which showed marked dilatation of the 1st two portions of the duodenum with an abrupt transition point and distended colon with fecal material without evidence of obstruction. An upper GI series was obtained; which was remarkable for obstruction at the 2nd portion of the duodenum. NGT decompression of barium from the stomach was performed and endoscopy showed extrinsic compression between the 1st and 2nd portions of the duodenum. EUS was subsequently performed but could not confirm the stenosis; sonography was suspicious for annular pancreas. MRCP was performed showing glandular parenchymal atrophy of the pancreatic body and tail and partial annular pancreas causing obstruction of the 2nd portion of the duodenum. Over the next few days her insulin regimen was titrated and her symptoms improved with subsequent discharge. On follow-up she and her family ultimately declined surgical or duodenal stent placement due to the patient's multiple comorbidities. DISCUSSION: Although most asymptomatic annular pancreas never cause problems, they can still become symptomatic. The patient's annular pancreas likely resulted in partial bstruction which contributed to recurrent misdiagnosed pancreatitis. This resulted in impairment of her pancreatic function, worsening her DM thus potentiating her labile diabetes. Additionally, years of fibrosis and scarring from inflammation of her annular pancreas likely lead to her eventual duodenal narrowing, further exacerbating symptoms.

1417 Gastric Outlet Obstruction Caused by Infiltrative Pancreatic Cancer Mimicking Benign Peptic Ulcer Disease

INTRODUCTION: Gastric outlet obstruction (GOO) is a known complication of peptic ulcer disease (PUD) and pancreatic cancer. Pancreatic cancer causing GOO can sometimes be missed on endoscopic ultrasound (EUS) due to limited access, thus presenting a diagnostic challenge. We report a case of pancreatic cancer causing GOO which was missed on EUS and GOO was attributed to the duodenal ulcers. CASE DESCRIPTION/METHODS: A 59-year-old man with medical history of diabetes and PUD presented with epigastric pain and persistent vomiting for last 2 months associated with weight loss. He had upper endoscopy 4 weeks prior that revealed multiple ulcers in second part of the duodenum. Exam was remarkable for epigastric tenderness. Laboratory data showed hypokalemic metabolic alkalosis and acute kidney injury. Liver function tests were normal. Considering patient's clinical presentation an underlying malignancy was high on differential. CT abdomen showed GOO with duodenal narrowing and a normal pancreas. Endoscopy showed duodenal bulb stricture which could not be traversed. Biopsy showed inflamed duodenal mucosa. EUS showed no pancreatic pathology. GOO was attributed to the duodenal ulcers noted on prior endoscopy and a Roux-en-Y gastrojejunostomy was performed. He returned 12 weeks later with painless jaundice and elevated liver enzymes. MRI abdomen revealed a 2.5 cm infiltrative pancreatic head tumor extending to the pancreaticoduodenal groove resulting in dilatation of the duodenal stump and bile duct. The patient underwent Whipple's pancreaticoduodenectomy. The histopathology showed pancreatic adenocarcinoma with distal involvement of the duodenal margin. DISCUSSION: Pancreatic cancer is the second most common malignancy causing GOO. EUS is the most sensitive diagnostic modality for pancreatic cancer with a sensitivity of 94%. However, its accuracy can be limited in setting of duodenal stricture and infiltrating type of the pancreatic lesion. The best station to evaluate the head and genu of the pancreas is second part of the duodenum. In case of duodenal stricture, EUS cannot be stationed properly and can miss an infiltrating pancreatic head lesion causing the GOO, which can be attributed to some other co-existent etiology like PUD, especially in the setting of normal liver tests and CT abdomen. This case also highlights the utility of MRI which is more sensitive than CT in diagnosing small pancreatic lesions and sometimes might be the only revealing modality in instances where EUS is limited by duodenal stricture.

1386 Narrow Tunnel, Zero Visibility: Role of Lumen-Apposing Metal Stent in the Treatment of Short Luminal Stricture Prior to Endoscopic Retrograde Cholangiopancreatography Procedure

INTRODUCTION: Managing short-segment benign gastrointestinal (GI) strictures can be challenging if they become refractory to conventional endoscopic therapies. Even though lumen-apposing metal stents (LAMS) are approved for access to and drainage of pancreatic fluid collections, endoscopists are using it in off label manner to treat these short GI luminal strictures. Here we present a patient with short duodenal stricture who was treated with LAMS, resulting in improvement of duodenal patency to accomplish ERCP. CASE DESCRIPTION/METHODS: 69-year-old male with signs of obstructive jaundice (choledocholithiasis) could not get ERCP due to a large duodenal ulcer and associated duodenal stricture. He underwent percutaneous biliary drainage (PTC), treated with antibiotics and later internalization of biliary plastic stent through interventional radiology. Three months later, follow up endoscopy showed healed duodenal ulcer but persistent duodenal stricture. CT revealed proximal migration of the biliary stent. Esophagogastroduodenoscopy was done and under endoscopic and fluoroscopic guidance, a 20 mm LAMS was placed across the duodenal stricture (measured to be <1 cm) with its Distal flange of LAMS was deployed first followed by proximal flange successfully. Two weeks later, the site was found to be patent with the LAMS intact. LAMS was removed with rat tooth forceps without any complication and ERCP was accomplished easily through improved duodenal lumen. Migrated biliary stent was removed and duct was cleared of stones and sludge followed by placement of 10 mm by 60 mm fully covered biliary metal stent and treatment with antibiotics. DISCUSSION: Our case represents another success story of treatment of short GI luminal stricture with LAMS in a patient who required ERCP and eventually had it after duodenal stricture treatment. The short length and wide flanges make LAMS potentially an attractive alternative treatment for short GI luminal stricture without any significant complications and better patient tolerance. Long term data and efficacy still needs to be studied. However, it is likely to continue to substitute as an alternative to traditional endoscopic option for short GI luminal stricture.

2034 Upper GI Bleed in a Young Male: A Rare Presentation of Eosinophilic Gastroenteritis

INTRODUCTION: Eosinophilic gastroenteritis (EGE) is a rare idiopathic disease affecting multiple organs (stomach and small intestine) of the gastrointestinal tract (GIT). It is characterized by eosinophilic infiltration of the bowel wall to a variable depth and symptoms associated with GIT. Klein et al classified EGE into 3 subtypes predominant mucosal, muscular or subserosal. The prevalence has been found to be ranging from 8.4 to 28 per 100,000. CASE DESCRIPTION/METHODS: Our patient is 28-year-old male with PMHx EGE, duodenal ulcers and stricture who presented to hospital with chief complaint of 3 episodes of dizziness and melena for one day. Allergies included food allergies to peanuts. Home medications included prednisone, montelukast and pantoprazole. On admission he was found to be tachycardic (150). Initial labs showed a hemoglobin (hgb) of 9.3. His hospital course included 1 episode of large volume hematemesis >1.5L and brief loss of consciousness followed up by a rapid response. Between day 1 and 2, hgb dropped to 5.7; patient received blood transfusion and managed conservatively with continuous vital monitoring in ICU. Emergent endoscopy (EGD) revealed high grade duodenal stenosis, severe pyloric-duodenal deformity with duodenal ulcer with visible vessel and 2 clips were deployed blindly. Epinephrine could not be injected due to hard and fibrotic tissue around duodenal stenosis. IR was consulted; angiography revealed active bleeding from gastric artery. Cool in and with a subsequent embolization was done. He received 5 unit RBCs total and continued on pantoprazole. For his known duodenal stricture, surgery was consulted with recommendation of no acute surgical intervention in the hospital. On discharge he was sent home with PO PPI, prednisone 40 daily, liquid diet, hydration and close follow up with GI, Surgery and PCP as soon as possible. DISCUSSION: EGE is more common in pediatric population and affects adults between the 3rd and 5th decade of life with a female predominance in USA. The risk factors include: genetic factors observed in familial cases, higher socioeconomic status, Caucasian race and excess weight. EGE is seen in patients with various allergies, asthma and elevated serum IgE levels, suggesting an association with hypersensitivity involved in the pathophysiology of EGE. 3 clinical criteria used to diagnose EGE: Presence of gastrointestinal symptoms; Gastrointestinal eosinophilic infiltrates; Exclusion of causes of tissue eosinophilia such as drug reactions or parasitic infections.

2659 A Rare Occurrence: Anal Squamous Cell Carcinoma With Metastasis to Duodenum Causing Duodenal Stricture and Gastric Outlet Obstruction

INTRODUCTION: Squamous cell carcinoma (SCC) of the anal canal is a rare entity encompassing only 2–4 percent of all colon, rectal, and anal cancers. SCC of the anal canal tends to be loco-regional and in the event of rare metastasis, most common sites of secondary seedlings are liver and lung. To our knowledge, metastatic spread from primary anal SCC to small bowel has been reported only once before. We report a rare case of SCC of anal canal with duodenal metastases in a 49-year-old female. CASE DESCRIPTION/METHODS: A 49-years-old female with 8-month history of anal SCC Stage IIIA, status post chemo-radiation therapy and loop ileostomy creation, was seen for complaints of vague abdominal pain, nausea, vomiting, and anorexia. Physical examination was significant for mild periumbilical tenderness. Computed tomography (CT) of the abdomen and pelvis with contrast revealed distended stomach with food contents and distended proximal duodenum. Esophagogastroduodenoscopy (EGD) showed moderate gastritis with duodenal edema resulting in narrowing of the second portion of the duodenum. An upper gastrointestinal series revealed distended stomach with air-fluid level and marked narrowing at the junction of the distal descending and transverse duodenum with "U-shaped" appearance and normal appearing jejunum. Colonoscopy via the stoma revealed normal colon proximal to diverting colostomy, normal terminal ileum, narrowed and scarred rectal vault. Biopsy from the duodenal stricture revealed duodenal mucosa with scattered malignant cells and malignant cell clusters within lymphatic spaces. Immunohistological staining demonstrated malignant cells positive for CK7, p16, p63 and negative for CK20, CDX2, GATA-3, CA19.9, TTF-1, Napsin A and PAX-8 favoring a metastatic anal SCC. DISCUSSION: Primary rectal squamous cell carcinomas (SCC) are very rare tumors. Additionally, either primary or metastatic SCC of the gastrointestinal tract is extremely rare with very few cases reported in the literature. In our case, the patient with established 8-month history of anal SCC stage IIIA, status post chemotherapy, radiation, and status post loop ileostomy creation presented with a rare duodenal metastasis, which has only been reported once before. The possibility of primary SCC of the small bowel was excluded with duodenal stricture biopsy showing scattered malignant cells and malignant cell clusters within lymphatic spaces and positive immunohistological staining favoring a metastatic lesion.