Gastric Outlet Research Articles

Endoscopic ultrasonography guided endoscopic necrosectomy in the treatment of walled-off pancreatic necrosis: Case report

Walled-off pankreatik nekroz, akut nekrotizan pankreatitin geç aşamasında gelişen ciddi bir lokal komplikasyondur. Nekrotik içerik enfekte olduğunda, hayatı tehdit eden bir komplikasyon haline gelir. Hastaların yarısında basınç, enfeksiyon, mide çıkış ve biliyer obstrüksiyonu ile ilişkili semptomlar gelişir. Semptomatik hastalarda organize nekrotik materyalin debridmanı gerekir. Eskiden, walled-off pankreatik nekrozun standart tedavisi açık cerrahi yöntem olsa da yüksek morbidite ve mortalite ile ilişkilidir. Bu nedenle, radyolojik ve endoskopik gibi minimal invaziv yöntemlerin ortaya çıkmasıyla açık cerrahinin rolü giderek azalmıştır. Günümüzde özellikle endoskopik ultrasonografi ile birlikte endoskopik teknikler ve aksesuarlardaki gelişmeler, peripankreatik sıvı koleksiyonlarının endoskopik tedavilerinde devrim yaratmıştır. Diğer yöntemlere göre daha düşük morbidite, mortalite ve hastanede kalış süresi ile ilişkili olan endoskopik yöntemler giderek daha çok tercih edilmektedir. Bu yazıda, endoskopik ultrasonografi eşliğinde transluminal drenaj ve endoskopik nekrozektomi yapılan walled-off pankreatik nekroz olgusunu sunuyoruz.

Failure to Thrive and Vomiting in a 32-day-old Girl.

Failure to Thrive and Vomiting in a 32-day-old Girl.

S2181 An Endoscopic Approach to an Unusual Cause of Gastric Remnant Outlet Obstruction After Roux-en-Y Gastric Bypass

S2181 An Endoscopic Approach to an Unusual Cause of Gastric Remnant Outlet Obstruction After Roux-en-Y Gastric Bypass

Gastric bypass outlet reduction by use of a single-channel endoscope.

Gastric bypass outlet reduction by use of a single-channel endoscope.

In Search of the Optimal Outcome Measure for Patients with Advanced Cancer and Gastrointestinal Obstruction: A Qualitative Research Study.

Gastrointestinal obstruction (GIO) is the most common indication for palliative surgical consultation in patients with advanced cancer. The purpose of this study is to delineate the symptom burden and experience of these patients. Twenty patients with advanced cancer and GIO described symptoms at time of surgical consultation. We analyzed the content of interview transcripts and ranked symptoms by frequency and according to an assessment of relevance conducted by an expert panel (surgeons, palliative care physicians, nurses, and patients/caregivers). Among the 20 study patients, malignancy types included colorectal (n = 9), gastric (n = 4), urothelial/renal (n = 3), and other (n = 4), whereas sites of obstruction were the small bowel (n = 11), gastric outlet (n = 3), and large bowel (n = 6). Thirteen patients (65%) had received chemotherapy within 6weeks. Imaging evidence of a primary/recurrent tumor was documented in 13 patients (65%), carcinomatosis in 11 (55%), and ascites in 16 (80%). Thirty patient symptoms were identified on qualitative interviewing. Seven GIO-specific items were identified as relevant by the expert panel and will be added to the core symptom assessment inventory for further testing. We identified symptoms of importance that can be used to assess outcome after treatment of patients with advanced cancer and GIO. Testing for validity and reliability will be required before formal survey development.

A133 DEVELOPMENT OF TYPE 3 ACHALASIA WITH DISTANT PANCREATIC MALIGNANCY

Abstract Background Pseudoachalasia is often caused by malignant involvement at the gastroesophageal junction (GEJ) leading to dysphagia. Aims We describe a case of type 3 achalasia presenting in a woman with metastatic pancreatic cancer with no direct involvement at the GEJ, fundus or cardia. Methods A case report and literature review were performed. Results A 53-year-old woman presented with a 2-month-history of progressive abdominal pain, nausea and vomiting with a 30-pound weight loss. She had a remote history of breast cancer in remission after surgery and chemoradiation. On presentation, she denied chest pain, reflux, dysphagia or odynophagia. Abdominal exam revealed focal epigastric tenderness and jaundice. Abdominal CT showed a 6.7 x 5.8 cm conglomerate mass involving the hepatic hilum, pancreatic head, duodenum, common bile duct, and portal vein with gastric outlet and biliary obstruction. This mass was confirmed to be a pancreatic adenocarcinoma on pathology. She then underwent nasogastric tube decompression. Initial esophagogastroduodenoscopy (EGD) confirmed a stenotic area at the distal duodenal cap. A duodenal stent and common bile duct stent were placed during a second EGD. The esophagus and GEJ were unremarkable on both endoscopic exams. She was started on chemotherapy with gemcitabine and abraxane. Two weeks after her stent placement, she rapidly developed severe retrosternal squeezing discomfort and choking occurring with swallowing. CT chest and abdomen were negative for any intrathoracic and diaphragmatic involvement with stability of the mass. A barium swallow study demonstrated tertiary contractions in the thoracic esophagus with marshmallow hold-up in the distal esophagus. She then underwent a high-resolution esophageal manometry study that demonstrated an elevation of integrated residual pressure (IRP) of the lower esophageal sphincter (LES) and absence of peristalsis, with the distal 2/3rds of the esophagus showing a simultaneous and prolonged pressure front consistent with type 3 achalasia, Chicago classification v3.0 [Figure 1]. All contractions had a distal contractile integral (DCI) of >8000 mmHg-cm-s. She experienced significant symptom improvement with pinaverium bromide, a gut-specific calcium channel antagonist. A review of the literature revealed that there have been 4 English-language cases published on pseudoachalasia associated with pancreatic cancer, with all cases describing direct infiltration of pancreatic cancer in the GEJ, cardia or fundus with manometric features of type I achalasia. Conclusions We report the first case of type 3 achalasia with no evidence of direct malignant infiltration at the GEJ on radiographic and endoscopic evaluations. Possible mechanisms to explain this phenomenon include paraneoplastic antibody-mediated impairment of enteric neurons that decrease nitric oxide availability, or microscopic disease involvement at the GEJ. Funding Agencies None

The role and place of endoscopic stenting in palliative care for patients with gastric and duodenal outlet obstruction

The role and place of endoscopic stenting in palliative care for patients with gastric and duodenal outlet obstruction

2556 Duodenal Candidiasis Presenting as Mass-Like Lesion: A Rare Presentation

INTRODUCTION: Candida is a normal inhabitant in the GI tract. It is typical for candidiasis to appear in the esophagus and oropharynx in immunocompromised patients. However, candidiasis of the stomach or duodenum is rare. We report a case of a gastric outlet and biliary obstruction due to a duodenal mass-like lesion in the setting of duodenal candidiasis. CASE DESCRIPTION/METHODS: Patient is a 66 year old female with past medical history of diabetes mellitus type 2, hypertension and osteoarthritis who presented to the hospital with progressive non-bloody vomiting, poor oral intake and constipation for two months. She endorsed abdominal pain and yellowing of the eyes and skin. Her vitals on admission were normal. Physical exam was pertinent for diffuse abdominal tenderness and scleral icterus. Her laboratory findings were significant for AST of 137 U/L, ALT of 130 U/L, alkaline phosphatase of 205 U/L, total bilirubin of 8.9 mg/dL and direct bilirubin of 5.3 mg/dL. Abdominal CT scan showed duodenal thickening with possible mass-like lesion causing gastric outlet obstruction. MRI of the abdomen and MRCP only showed duodenal wall thickening. She had a subsequent EGD that showed mild gastric erythema and a mass like lesion in the duodenum hindering the visualization of the papilla. Biopsy results were significant for active chronic duodenitis with presence of Candida albicans. Gastric biopsy was positive for H. pylori infection. The patient was treated with a 21 day course of Fluconazole followed by bismuth based quadruple therapy. Follow-up EGD showed resolution of the duodenal lesion. At two months follow up after treatment, the patient had no symptoms and liver enzymes were normal. DISCUSSION: Candida is part of the normal flora of the GI tract and commonly causes infection in the mouth and esophagus. Stomach and duodenal infections are less common due to their relatively acidic environment creating a harsh environment for the fungal species to grow and cause disease. However, immunocompromised patients and patients on acid suppressive therapy are vulnerable to opportunistic candidal infection. The long standing history of diabetes may have predisposed patient to the infection. In conclusion, our case highlights a rare presentation of a duodenal candidal infection; mass-like lesion causing gastric outlet and biliary obstruction. This case should serve as a reminder to clinicians to keep candidiasis in the differentials for duodenal infections especially in diabetic patients.

Differential GIP/GLP-1 intestinal cell distribution in diabetics' yields distinctive rearrangements depending on Roux-en-Y biliopancreatic limb length.

As incretins are known to play an important role in type 2 diabetics (T2D) improvement observed after Roux-en-Y gastric bypass (RYGB), our aim was to assess whether increasing the length of RYGB biliopancreatic limb in T2D would modify the incretin staining cell density found after the gastric outlet. Small intestine biopsies (n = 38) were harvested during RYGB at two different distances from the duodenal angle; either 60-90 cm (n = 28), from non-diabetic (n = 18) patients, and T2D (n = 10), or 200 cm (n = 10) from T2D. GIP and GLP-1 staining cells were identified by immunohistochemistry and GLP-1/GIP co-staining cells by immunofluorescence. Incretin staining cell density at the proximal small intestine of T2D and non-diabetic individuals was similar. At 200 cm, T2D patients depicted a significantly lower GIP staining cell density (0.181 ± 0.016 vs 0.266 ± 0.033, P = 0.038) with a similar GLP-1 staining cell density when compared to the proximal gut. GIP/GLP-1 co-staining cells was similar in all studied groups. In T2D patients, the incretin staining cells density in the distal intestine is significantly different from the proximal gut. Thus, a longer RYGB biliopancreatic limb produces a distinctive incretin cell pattern at the gastro-enteric anastomosis that can result in different endocrine profiles.

Selective Approach for Patients with Advanced Malignancy and Gastrointestinal Obstruction

The purpose of this study was to determine the frequency of tumor-related gastrointestinal obstruction and identify variables associated with functional outcomes and survival in patients with advanced malignancy and gastrointestinal obstruction. We reviewed the medical records of 490 patients with advanced cancer, who underwent surgical consultation for gastrointestinal obstruction between January 2000 and May 2014. We used chi-square and logistic regression analyses to identify variables associated with survival and eating at discharge. Obstructions were tumor-related in 334 (68%) patients, adhesion-related in 96 (20%), and of unclear etiology in 60 (12%). The obstruction site was the gastric outlet in 78 (16%), small bowel in 312 (64%), and large bowel in 100 (20%). Treatment was classified as medical (49% of patients), surgical (32%), and procedural (interventional radiology or endoscopy) (17%). Sixty-eight percent of patients were eating at the time of discharge, and 42% died within 90 days of surgical consultation. Median overall survival rates for patients managed with procedural, medical, and surgical treatment were 69, 135, and 314 days, respectively (p < 0.001). Intact primary/local recurrence, carcinomatosis, and albumin level <3.5 g/dL were negatively associated with eating at discharge. Compared with medical management, surgery was not associated with the ability to eat. Variables associated with death within 90 days of consultation included an intact primary/local recurrence, carcinomatosis, abdominal visceral metastasis, and procedural treatment. Patients managed with surgery demonstrated improved survival on unadjusted analysis. However, on multivariate analysis that included the imaging extent of disease, surgery was not associated with outcome, which highlights the importance of patient selection and the need for additional research to identify variables critical for treatment selection.

Gastric outlet and ileal obstruction due to recurrent persimmon phytobezoar: clinical image

Gastric outlet and ileal obstruction due to recurrent persimmon phytobezoar: clinical image

A case report of brunner gland adenoma

Brunner gland adenoma are rare tumor and etiology remains obscure. Bleeding is the most common symptom, Gastric outlet or duodenal obstruction may also occur. The incidence is less than 5%. This case is presented here for rarity of clinical presentation. A 69 years female came with history of melena . Gastroduodenoscopy diagnosed with duodenal polyp.

In search of the optimal outcome measure for patients with advanced cancer and gastrointestinal obstruction: A qualitative research study.

100 Background: Gastrointestinal obstruction (GIO) is the most common indication for palliative surgical consultation in patients with advanced cancer. The purpose of this study was to delineate the symptom burden and experience of patients with GIO. Methods: Twenty patients with advanced cancer and GIO described symptoms at the time of surgical consultation. We used content analysis of interview transcripts and symptoms were ranked by frequency and compared to a general symptom assessment survey (MD Anderson Symptom Inventory). Results: Malignancy type included colorectal (N = 9), gastric (N = 4), urothelial/renal (N = 3), and other (N = 4), while site of obstruction was small bowel in 11 (55%), gastric outlet in 3 (15%), and large bowel in 6 (30%). Thirteen patients (65%) had received chemotherapy within 6 weeks. Imaging evidence of a primary/recurrent tumor, carcinomatosis, or ascites was documented in 13 (65%), 11 (55%), and 16 (80%) patients, respectively. Thirty symptoms were identified on qualitative interviewing. MD Anderson Symptom Inventory symptoms of pain, nausea, and vomiting were frequently noted. Frequently mentioned GIO-specific symptoms included bloating, cramping, not having a bowel movement, and inability to eat. Conclusions: Qualitative research methodology can identify symptoms of importance to patients which can be used to assess improvement after treatment of GIO. Expert panel rating will be used to develop the final symptom item list prior to psychometric testing of the survey.

Management of Ruptured Pancreatic Pseudocyst with Fistulous Communication to the Duodenum

Introduction: Pancreatic pseudocysts (PPC) are inflammatory fluid collections in the pancreas or peripancreatic space, and are often the complication of acute/chronic pancreatitis. PPC are usually asymptomatic, but can present with wide array of symptoms such as abdominal pain, upper gastrointestinal bleeding, nausea, vomiting, and gastric and bile duct compression leading to early satiety and jaundice. Rupture of PPC with fistula formation with the gastrointestinal tract is rare complication, with only a few cases reported in literature. Case Presentation: This is a 64-year-old female with history of cirrhosis, chronic pancreatitis, and PPC who was transferred from an outside hospital (OSH) for management of increasing size of PPC. CT abdomen at the OSH showed increased size of PPC from 45 mm to 88 mm in 6 months, resulting in gastric outlet and common bile duct obstruction. OSH records showed leukocytosis (28,100 cells/uL), alkaline phosphatase (637 U/L), total bilirubin (3 mg/dL), ALT/AST (58/82 U/L). At OSH, the patient was placed on broad spectrum antibiotics and an EUS was performed, which showed a large pseudocyst measuring 10x9 cm at the head of the pancreas, with 7x5 cm area of debris. Transdoudenal aspiration of the pseudocyst yielded debris with thick mucinous fluid; second attempt revealed bloody fluid. At our hospital, an EUS was attempted to drain the pseudocyst, which revealed necrotic PPC with a fistula connecting to the duodenum. Further evaluation revealed bloody clots and fluid filled debris within the necrotic cavity and duodenum. No drainage was attempted; it was felt that the pseudocyst would self-resolve by draining into the duodenum. Follow up CT showed decreased PPC size. The patient's symptoms improved.Figure 1Figure 2Discussion: Spontaneous rupture of PPC and fistula formation is a very rare occurrence with very few cases reported. Due to the paucity of cases in the literature, there are no clear guidelines on the management of a ruptured pseudocyst. PPC are usually treated via three main mechanisms: percutaneous drainage, surgical intervention, or endoscopic transpapillary or transmural drainage. Endoscopic drainage is the preferred method of treatment because it carries lower risk of complication, with similar rates of success as surgery. However, if the pseudocyst develops a fistula with the gastrointestinal tract, the pseudocyst can self-resolve by draining directly into the digestive tract, without intervention.

Pancreatic Necrosis: A Single Center Epidemiologic Description

Introduction: Pancreatic necrosis is a complication of acute pancreatitis which results in the formation of walled-off collections that may contain both solid debris and liquid elements. Necrotic collections have a tendency to get infected and can cause other major complications including abdominal pain, mass effect resulting in gastric outlet or biliary obstruction, pseudo aneurysms or septic shock. This study analyzes the epidemiology of patients suffering from pancreatic necrosis and the characteristics of the necrotic cavity.Figure 1Figure 2Methods: This study was a retrospective review of 85 patients who were treated for pancreatic necrosis at our institution over a five year period (December 2010 - October 2015). We collected epidemiologic data pertaining to these patients, the severity of their episode of acute pancreatitis, clinical features as well as details regarding the necrotic cavity. Results: The mean age of patients treated for pancreatic necrosis at our institution was 53.7 ± 15 years. 72% of them were males and 84% were Caucasians. Median scores for the Charlson comorbidity index and the Bedside Severity of Index in Acute Pancreatitis (BISAP) was 2 for both. Most common cause of acute pancreatitis preceding pancreatic necrosis was gallstone disease (33%) followed by alcoholinduced pancreatitis (30%). (Table 1) Mean dimensions of the necrotic cavity were 79.4mm × 67.5mm × 91.3mm. Most necrotic collections were observed to involve the majority of the pancreas (45%), however the pancreatic body was the most commonly affected if the necrosis was localized (33%). Around 50% of necrotic collections were infected, however only 27% of patients were found to be bacteremic. (Table 2). Conclusion: Pancreatic necrosis is a known and serious complication of acute pancreatitis. Amongst all causes of acute pancreatitis, gallstone pancreatitis was associated with a higher rate of complicating into pancreatic necrosis. Although infected pancreatic necrosis is an indication for debridement, not all infected cysts result in peripheral bacterial seeding and sepsis. Hence, not all infected cysts may need debridement and further studies are needed to establish which patients may benefit from any kind of intervention versus just conservative management.

An unusual reason of abdominal pain: A case of Rapunzel's syndrome and literature review

Bezoar is defined as a mass formed as a consequence of the accumulation of indigestible foreign substances within the gastric outlet or small bowels with resultant dysfunctional gastric emptying Gastric bezoar extending into the small or large bowel and causing a clinical condition called Rapunzel syndrome This rare pediatric condition is observed in young girls with psychiatric problems such as trichotilomania, who frequently feel an irresistable desire to pluck out, and swallow their hairs. A 12-year-old girl was admitted to our hospital with complaints of abdominal pain, growth retardation, and partial hair loss. Endoscopic examination revealed the presence of gastroduodenale trichobezoar, and her giant trichobezoar was extracted using conventional laparotomy, and anterior gastrostomy. With this case representation we reported a case with Rapunzel Syndrome in the light of literature data.

Gastric adenomyoma causing outlet obstruction

Adenomyoma of stomach is a rare condition that may or may not present with symptoms, often depending on the location of the tumor. Here, we present a case of gastric adenomyoma with pancreatic heterotopia in the pyloric region causing outlet obstruction. Clinically, radiologically, and histologically adenomyoma of the stomach may mimic gastric malignancy. Awareness of this lesion is necessary to avoid misdiagnosis of the condition.

A Case of Pancreatic Adenosquamous Carcinoma Obstructing the Common Bile and Pancreatic Ducts, Duodenum, and Gastric Outlet

A 76-year old Caucasian female was admitted for a 6 week-history of nausea, vomiting, abdominal pain, and a 20-pound weight loss. No tobacco or alcohol consumption and no previous history of pancreatic disease or familial pancreatic cancer were reported. Vital signs were within normal. Physical exam was notable for epigastric tenderness. Serum lipase, alkaline phosphatase, and cancer antigen 19-9 were elevated. Other routine laboratory test results were non-contributory. Contrast-enhanced computed tomography (CECT) of the abdomen and pelvis showed a 2.7 by 3.5 cm heterogeneously enhancing mass in the head of the pancreas causing obstruction of the common bile duct (CBD) and stomach and nearly occluding the portal vein at the confluence. EUS identified an irregular, hypo-echoic mass in the pancreatic head measuring 40 by 35 mm in maximal cross-sectional diameter with intact interference between the mass and the adjacent structures suggesting lack of invasion. Several peritumoral malignant, appearing lymph nodes were also identified by EUS. The pancreatic duct and CBD were dilated at 4 and 20 mm in diameter respectively. EUS-FNA biopsy was performed using a 22-gauge Wilson-Cook EchoTip biopsy needle via a transduodenal approach. Cytological and immunohistochemistry (IHC) staining showed the presence of two components of cells; adenocarcinoma and squamous carcinoma. Based on clinical exam, CECT, EUS-FNA biopsy, and IHC staining, a diagnosis of locoregional PASC was made. Pancreatic cancer is the fourth leading cause of cancer deaths in the USA. PASC is rare, more aggressive, and makes only 0.5 % of pancreatic cancer. This is a rare case of PASC obstructing multiple gastrointestinal and hepatobiliary sites and presenting without jaundice or significant elevation in bilirubin. The combination of CECT with EUS seems to produce the highest accuracy for staging and diagnosing pancreatic neoplasm and for assessing the respectability of the tumor. Cytology and IHC staining of collected EUS-FNA biopsies showed a dual population of malignant glandular cells with intracellular mucin production as well as pleomorphic squamous cells making greater than 30 % of malignant cells; meeting histological criteria of PASC. The application of the CECT/EUS-FNA modality helped characterize the tumor resectability in our patient. In a locoregional PASC, tumor resectability is the strongest independent predictor of to survival. The patient underwent surgical tumor resection successfully and will be followed up.Figure 1Figure 2Figure 3

EUS-guided Endoscopic Transduodenal Necrosectomy in a Patient With Sleeve Gastrectomy

Walled-off pancreatic fluid collections (PFC) occur after an acute attack of pancreatitis in approximately 10 percent of cases. Decompression of the collection is advocated when specific indications are met, such as pain, gastric outlet or biliary obstruction, fluid leakage, fistulization, weight loss and infection. Endoscopic drainage has been widely adopted as the primary approach for symptomatic walled-off PFC. Difficulty can arise in cases of altered gastric anatomy, as the procedure requires an adequate amount of space to maneuver. We present the first case of a patient with sleeve gastrectomy who underwent successful endoscopic transduodenal necrosectomy (TDN). 40 year old woman with history of morbid obesity status post sleeve gastrectomy in 2009 with intermittent post-prandial RUQ abdominal pain was found to have symptomatic gallstone disease. Patient's course was complicated by severe necrotizing gallstone pancreatitis and further complicated by symptomatic walled off pancreatic necrosis (WOPN). Imaging at 8 weeks revealed 10.8 x 7.6 cm fluid collection with portions of solid components seen in the body and tail of the pancreas. The decision was made to attempt endoscopic necrosectomy. EGD revealed a tubular gastric body and antrum, with extrinsic compression in the antrum and duodenal bulb from the pancreatic cyst. Duodenal bulb was selected as the preferred fistula site due to sleeve gastrectomy. The patient underwent successful TDN with placement of three 10Fr pigtail stents. Patient had symptomatic improvement and was discharged to outpatient follow-up. Although the transgastric approach is preferred for walled-off PFC, usually due to more favorable location, as well as the comfort level of endoscopists, there is no definite evidence that transgastric drainage is superior to transduodenal drainage. The duodenal approach was used in our patient as sleeve gastrectomy involves removal of the stomach body and a large portion of the antrum producing a high pressure system inside the stomach which may lead to inadequate drainage. Additionally, intervention adjacent to the staple line may predispose to anastomotic leak and break down of the staple line. One prior case has been reported of a patient with sleeve gastrectomy undergoing laparoscopic cyst-gastrostomy after aborted endoscopic cyst-gastrostomy due to limited working space and the inability to visualize the posterior aspect of the stomach. Although laparoscopic cyst-gastrostomy is an acceptable approach for these patients, randomized trials have demonstrated equal efficacy between endoscopic and surgical luminal pancreatic pseudocyst drainage, with endoscopic treatment associated with shorter hospital stays and lower cost. This case illustrates the feasibility of endoscopic necrosectomy in patients with altered gastric anatomy.Figure 1Figure 2Figure 3

Su1515 Gastric Pouch Anastomotic Outlet Reduction Using the Endoscopic Over the Scope Clip System for Weight Regain After Roux-EN-Y Gastric Bypass

Su1515 Gastric Pouch Anastomotic Outlet Reduction Using the Endoscopic Over the Scope Clip System for Weight Regain After Roux-EN-Y Gastric Bypass