Repeat Endoscopy Research Articles

Anatomical Configuration of the Stomach Post-Endoscopic Sleeve Gastroplasty (ESG)-What Are the Sutures Doing?

Endoscopic sleeve gastroplasty (ESG) is a procedure in which endoscopically placed sutures involute the stomach and promote weight loss. There is limited data on the durability of these sutures. This was a single center series of 5 patients who underwent ESG performed by a single endoscopist. Patients underwent repeat endoscopy for different clinical indications. ESGs were successfully reversed at 3weeks and 1month following index ESG without significant fibrosis or scaring. At 8 and 14months, a few sutures had dehisced though there were extensive areas of fibrosis. By 2years, most of the sutures had dehisced; however, the gastric volume remained reduced. This case series offers an intriguing evaluation of the anatomical changes induced by ESG.

Gastric Pyloric Gland Adenoma: A Case Report, Review of Literature, and Diagnostic Challenges in the Philippine Setting

Pyloric gland adenoma (PGA) is a rare neoplasm with definite malignant potential that is difficult to recognize because of its characteristically bland histology. We present a case of a 74-year old female with chronic, intermittent symptoms referable to gastroesophageal reflux, bloatedness, and frequent flatus, with family history of gastric cancer. Initial endoscopy was done and biopsy revealed an inflammatory pseudopolyp. After six months, repeat endoscopy showed multiple polyps at the cardia, and biopsy of one of the visualized polyps was done. Microscopic sections of the polyp show a neoplasm composed of discrete glands lined by simple cuboidal to columnar epithelial cells with amphophilic to eosinophilic cytoplasm without apical mucin caps, and mild nuclear atypia. Mild epithelial stratification is noted in some of the glands. PAS staining showed granular, cytoplasmic staining in tumor cells. Immunohistochemical staining with P53 showed focal, weak, nuclear staining in tumor cells. Staining with Ki67, MUC2, MUC5AC, and MUC6 were not done because the tissue had already been exhausted. The diagnosis of PGA with low-grade dysplasia has been made. The patient is apparently well, and is advised surveillance endoscopy at six-month intervals. PGA may be diagnosed in a limited resource setting, through thorough histologic examination, and use of special histochemical stains.

Optimizing Management of Patients With Barrett’s Esophagus and Low-Grade or No Dysplasia Based on Comparative Modeling

Endoscopic treatment is recommended for patients with Barrett's esophagus (BE) with high-grade dysplasia, yet clinical management recommendations are inconsistent for patients with BE without dysplasia (NDBE) or with low-grade dysplasia (LGD). We used a comparative modeling analysis to identify optimal management strategies for these patients. We used 3 independent population-based models to simulate cohorts of 60-year-old individuals with BE in the United States. We followed up each cohort until death without surveillance and treatment (natural disease progression), compared with 78 different strategies of management for patients with NDBE or LGD. We determined the optimal strategy using cost-effectiveness analyses, at a willingness-to-pay threshold of $100,000 per quality-adjusted life-year (QALY). In the 3 models, the average cumulative incidence of esophageal adenocarcinoma was 111 cases, with costs totaling $5.7 million per 1000 men with BE. Surveillance and treatment of men with BE prevented 23% to 75% of cases of esophageal adenocarcinoma, but increased costs to $6.2 to $17.3 million per 1000 men with BE. The optimal strategy was surveillance every 3 years for men with NDBE and treatment of LGD after confirmation by repeat endoscopy (incremental cost-effectiveness ratio, $53,044/QALY). The average results for women were consistent with the results for men for LGD management, but the optimal surveillance interval for women with NDBE was 5 years (incremental cost-effectiveness ratio, $36,045/QALY). Based on analyses from 3 population-based models, the optimal management strategy for patient with BE and LGD is endoscopic eradication, but only after LGD is confirmed by a repeat endoscopy. The optimal strategy for patients with NDBE is endoscopic surveillance, using a 3-year interval for men and a 5-year interval for women.

Sickle Cell Disease Post-Transplant Care Challenges in Nigeria: Systematic Institutional Neglect of Medical Tourism

Introduction: Allogeneic hematopoietic stem cell transplantation (Allo-HCT) is potentially curative in eligible patients with sickle cell disease (SCD). Long term survival remains a challenge following allo-HCT and factors that predict for longer term complications and late mortality include increased hospitalization within the first 100 days, low socioeconomic status and poor access to healthcare. A new cottage industry of medical tourism associated with allo-HCT has emerged where children and adults with SCD living in Africa are traveling to countries that provide allo-HCT. Recent advances in improved disease-free survival and overall survival has resulted in families seeking curative options outside of their low resource-setting. The decision for allo-HCT is heavily weighed to family preference without regards to post-transplant care in their local environment. Unfortunately, the long-term care required for many children following an allo-HCT transplant is usually not available in their home country. Thus, the family desiring an allo-HCT is put in an awkward situation where they may need to have follow-up care in their primary country at a medical facility where neither the expertise nor the resources are available to manage long-term complications of allo-HCT. To explore the relationship between transplant medical tourism and patients with SCD, we report a case series of children who received their allo-HCT in another country only to return back to Nigeria. Methods: We recently established a post-transplant care clinic at the Lagos University Teaching Hospital, Idi-Araba, Nigeria. This includes a multidisciplinary team of providers, physicians and nurses with expertise in transplant care, and collaboration from Vanderbilt University Medical Center, USA. All cases described received allo-HCT outside Nigeria and returned within 60-100 days post-transplant. Parental preference for curative option was main indication for seeking allo-HCT. Records were obtained through electronic and paper medical records. Results: All the four cases reported had sickle cell anemia (Hb SS). Cases 1-3 received reduced intensity haploidentical HCT with post-transplant cyclophosphamide (Haplo-HCT), using G-mobilized peripheral blood stem cell grafts from parental donors with sickle cell trait. They all received preconditioning with hydroxycarbamide, azacytidine, and hypertransfusion (Table). Case-1 was 2years old, initially evaluated at day +135 post-transplant, complications included grade-II acute GI graft-versus-host disease (GVHD) at day+37 post-transplant, febrile illness and pseudo-membranous colitis requiring repeat endoscopies and prolonged steroid therapy. Case 2 was 5-years-old, seen day+395 post-transplant self-discontinued immunosuppression and antimicrobial prophylaxis with no guidance (despite the original haplo-HCT required a minimum of 12 months of immunosuppression therapy). Similarly, Case 3 was 7-years-old, off immunosuppression prematurely, and yet to commence routine post-transplant immunizations. Case 4 was 5-year-old who received matched related myeloablative bone marrow transplant. He was seen at day +138 post-transplant. He had poor graft function, EBV reactivation requiring Rituximab chemotherapy. Other management challenges encountered by patient's post-transplant include timely monitoring of immunosuppression and graft function, provision of irradiated blood component transfusion support, provision of anti-malaria and anti-helminthic prophylaxis which are endemic locally. Further, no physician to physician contact was made to transfer the patient back to a hematologist or oncologist with knowledge about post-transplant medical care. Discussion: The argument for performing the allo-HCT in children moving back to a low-income country has to be weighed against the availability of a strategy for management of late complications of allo-HCT, such as chronic GVHD, infectious complications related to immune reconstitution, as well as endocrine and chronic metabolic syndromes. Ultimately, the decision to perform an allo-HCT in such situations must be done on a case-by-case basis with a clear contingency plan to manage transplant-related complications for at least 2 years after the procedure at a hospital with adequate transplant expertise and support measures. Disclosures No relevant conflicts of interest to declare.

AGA Clinical Practice Update on Endoscopic Treatment of Barrett’s Esophagus With Dysplasia and/or Early Cancer: Expert Review

The purpose of this best practice advice article is to describe the role of Barrett's endoscopic therapy (BET) in patients with Barrett's esophagus (BE) with dysplasia and/or early cancer and appropriate follow-up of these patients. The best practice advice provided in this document is based on evidence and relevant publications reviewed by the committee. BEST PRACTICE ADVICE 1: In BE patients with confirmed low-grade dysplasia, a repeat examination with high-definition white-light endoscopy should be performed within 3-6 months to rule out the presence of a visible lesion, which should prompt endoscopic resection. BEST PRACTICE ADVICE 2: Both BET and continued surveillance are reasonable options for the management of BE patients with confirmed and persistent low-grade dysplasia. BEST PRACTICE ADVICE 3: BET is the preferred treatment for BE patients with high-grade dysplasia (HGD). BEST PRACTICE ADVICE 4: BET should be preferred over esophagectomy for BE patients with intramucosal esophageal adenocarcinoma (T1a). BEST PRACTICE ADVICE 5: BET is a reasonable alternative to esophagectomy in patients with submucosal esophageal adenocarcinoma (T1b) with low-risk features (<500-μm invasion in the submucosa [sm1], good to moderate differentiation, and no lymphatic invasion) especially in those who are poor surgical candidates. BEST PRACTICE ADVICE 6: In all patients undergoing BET, mucosal ablation should be applied to 1) all visible esophageal columnar mucosa; 2) 5-10 mm proximal to the squamocolumnar junction and 3) 5-10 mm distal to the gastroesophageal junction, as demarcated by the top of the gastric folds (ie, gastric cardia) using focal ablation in a circumferential fashion. BEST PRACTICE ADVICE 7: Mucosal ablation therapy should only be performed in the presence of flat BE without signs of inflammation and in the absence of visible abnormalities. BEST PRACTICE ADVICE 8: BET should be performed by experts in high-volume centers that perform a minimum of 10 new cases annually. BEST PRACTICE ADVICE 9: BET should be continued until there is an absence of columnar epithelium in the tubular esophagus on high-definition white-light endoscopy and preferably optical chromoendoscopy. In case of complete endoscopic eradication, the neosquamous mucosa and the gastric cardia are sampled by 4-quadrant biopsies. BEST PRACTICE ADVICE 10: If random biopsies obtained from the neosquamous epithelium demonstrate intestinal metaplasia/dysplasia or subsquamous intestinal metaplasia, a repeat endoscopy should be performed and visible islands or tongues should undergo targeted focal ablation. BEST PRACTICE ADVICE 11: Intestinal metaplasia of the gastric cardia (without residual columnar epithelium in the tubular esophagus) should not warrant additional ablation therapy. BEST PRACTICE ADVICE 12: When consenting patients for BET, the most common complication of therapy to be quoted is post-procedural stricture formation, occurring in about 6% of cases. Bleeding and perforation occur at rates <1%. BEST PRACTICE ADVICE 13: After complete eradication (endoscopic and histologic) of intestinal metaplasia has been achieved with BET, surveillance endoscopy with biopsies should be performed at the following intervals: for baseline diagnosis of HGD/esophageal adenocarcinoma: at 3, 6, and 12 months and annually thereafter; and baseline diagnosis of low-grade dysplasia: at 1 and 3 years. BEST PRACTICE ADVICE 14: Endoscopic surveillance post therapy should be performed with high-definition white-light endoscopy, including careful inspection of the neosquamous mucosal and retroflexed inspection of the gastric cardia. BEST PRACTICE ADVICE 15: The approach to recurrent disease is similar to that of the initial therapy; visible recurrent nodular lesions require endoscopic resection, whereas flat areas of columnar mucosa in the tubular esophagus can be treated with mucosal ablation. BEST PRACTICE ADVICE 16: Patients should be counseled on cancer risk in the absence of BET, as well as after BET, to allow for informed decision-making between the patient and the physician.

Gastrointestinal Mucosal Lymphoid Hyperplasia: Mutation in PIK3CD Gene.

A 4-year-old boy presented with difficulty defecating, hematochezia, and large rectal prolapse. Upper endoscopy and colonoscopy showed polypoid lesions throughout the colon and nodular mucosa of the esophagus, stomach, and duodenum (Fig. 1). Histology demonstrated mucosal florid lymphoid hyperplasia (Fig. 2). Workup revealed elevated inflammatory markers (erythrocyte sedimentation rate, C-reactive protein (ESR, CRP)), elevated fecal calprotectin, and positive QuantiFERON. Despite negative computed tomography (CT) chest, with negative for tuberculosis (TB) on his gastrointestinal biopsies, he was treated for latent TB with isoniazid. He had negative workup for lymphoma. Immunologic workup revealed decreased CD4 T-cells, CD21-positive cells, and increase in CD1-negative cells. Genetic testing revealed a heterozygous pathogenic mutation in phosphatidylinositol 3-kinase, catalytic, delta PIK3CD. This mutation is associated with activated phosphoinositide 3-kinase δ syndrome resulting in combined immunodeficiency disorder that can present with lymphoid hyperplasia of gastrointestinal and respiratory mucosal surfaces, recurrent infections, immunodeficiency, and/or malignancy (1). Patients with activated phosphoinositide 3-kinase δ syndrome may benefit from mammalian target of rapamycin (mTOR) inhibitors such as sirolimus or other immunosuppressants (2). Our patient was treated with budesonide and hydroxychloroquine as a bridge therapy to sirolimus while he was being treated for latent TB. Although his repeat endoscopy did not show major improvement, he had excellent clinical response, so he was maintained on the current regimen.FIGURE 1: A, Colon: lymphoid hyperplasia presenting as polypoid lesions. B, Duodenum: lymphoid hyperplasia presenting as nodular lesions.FIGURE 2: Lymphoid hyperplasia of the colonic biopsy. B, Lymphoid hyperplasia of the duodenum biopsy.

2014 Over-the-Scope Clip as Salvage Therapy for Refractory Non-Variceal Upper Gastrointestinal Hemorrhage After Failed Conventional Management: A Case Series

INTRODUCTION: Elderly patients with cardiovascular co-morbidities are of higher mortality risk from non-variceal upper gastrointestinal hemorrhage (NVUGIH). Traditional endoscopic interventions with through-the-scope-clips, electrocautery and epinephrine injections have a high failure rate at managing bleeding from large visible vessels, especially bleeding from posterior duodenal bulb ulcers. Over-the-scope-clips (OTSC) are preferred by endoscopists for their versatile role in repair of fistulas, bowel perforations and NVUGIH. We report two NVUGIH cases where traditional endoscopic and angiographic interventions failed and over the scope clip was used as salvage therapy. CASE DESCRIPTION/METHODS: 85-year-old female with Pulmonary Hypertension and Atrial Fibrillation was admitted for hypovolemic shock from hematemesis. Endoscopy revealed a large posterior duodenal bulb ulcer with adherent clot for which epinephrine injection was used. The ulcer’s size and location prompted angiography and coil embolization of the gastroduodenal artery (GDA). Patient was in hypovolemic shock again due to a massive bleed. She was high risk for surgical intervention due to pulmonary hypertension, and repeat endoscopy was performed for hemostasis. An 11/6 T-type OTSC clip was successfully deployed at a large vessel oozing blood, after removal of a large adherent clot by snare. No further intervention was needed afterward. 76-year-old male with extensive cardiac history was admitted with burns and inhalation injury from a house fire, requiring tracheostomy and gastrostomy placement. During hospitalization, patient had multiple episodes of melena and required blood transfusion. Endoscopy revealed two large anterior and posterior duodenal bulb ulcers, with a visible vessel, managed by electrocautery. Due to persistent bleeding, he underwent coil embolization of the GDA. Two days later, patient had recurrent bleeding. Repeat endoscopy with OTSC was used for successful hemostasis of a large visible vessel in the posterior duodenal bulb. DISCUSSION: Traditional endoscopic management carries a 20% re-bleeding risk and successful secondary hemostasis drops from 90% to 75%. Anatomic variation in blood supply to the duodenal bulb, either from branches of celiac axis or superior mesenteric artery may be the reason why our patients failed angiographic coil embolization of the GDA. To our knowledge, we report the first two cases where OTSC was used for successful salvage of NVUGIH that failed initial endoscopic and angiographic interventions.

3104 Esophageal Hematoma: A Colossal Obstacle

INTRODUCTION: Esophageal hematomas are rare but well described phenomena that can present as retrosternal chest pain, hematemesis, and dysphagia. They are seen in association with anticoagulation therapy, mechanical trauma, and increased intraesophageal pressure as caused by excessive retching and vomiting. We describe a case of esophageal hematoma following catheter ablation for treatment of atrial fibrillation. CASE DESCRIPTION/METHODS: A 73 year old female with chronic obstructive pulmonary disease, nephrectomy, rheumatic heart disease status post mechanical mitral valve on warfarin, refractory atrial fibrillation was admitted for hematemesis after elective atrial fibrillation ablation. The patient underwent TEE during which an esophageal probe was required for repositioning of the esophagus. No blood was seen when the probe was removed, but at the end of the procedure the patient had hematemesis. INR at presentation was 3.7. The patient was emergently intubated and an EGD revealed a large clot occluding the mid-esophagus, denuded mucosa with oozing from multiple sites, and a large clot in the fundus (Figure 1). A chest CTA showed circumferential esophageal thickening and distention with non-enhancing blood products extending from above the thoracic inlet to the GE junction, with clot also outlined by oral contrast within the gastric lumen. No definite communication between the esophagus and atrial pulmonary veins was identified. A repeat endoscopy the next day again showed the large esophageal hematoma (Figure 2) and was aborted to avoid additional esophageal trauma. A week later, CTA chest showed persistent esophageal intramural hematoma with no evidence of aortoenteric fistula. Cardiothoracic surgery was consulted and placed a percutaneous gastrostomy tube. The patient was recovering well, but shortly upon extubation, the patient died of cardiorespiratory arrest. DISCUSSION: Esophageal hematomas typically develop in middle-aged women and present as a triad of retrosternal chest pain, dysphagia and hematemesis. The mechanism producing the hematoma may determine the site. For example, a hematoma from vomiting would be at the esophagogastric junction, whereas from a caustic substance might be at points of narrowing. It can be visualised on endoscopy or as a filling defect on barium esophagogram. Computed tomographic images reveal a mass confined to the esophageal lumen that does not enhance with injection of contrast medium. Conservative and supportive care remains the main therapeutic modality.

1827 Concurrent Barret’s Esophagus and Esophageal Varix With Resolution After Banding

INTRODUCTION: Barret’s esophagus with dysplasia is a premalignant condition frequently treated with radiofrequency ablation. However, the management of concurrent dysplasia with esophageal varices (EV) is not defined. Medical literature on this topic is scant and consists of a few case reports. The following is a case of Barret's esophagus with low grade dysplasia and concurrent esophageal varices, successfully treated with band ligation. CASE DESCRIPTION/METHODS: The patient is a 50-year-old man with a history of liver cirrhosis, who presented to our gastroenterology clinic for routine evaluation. His only complaint was chronic heartburn. EGD was significant for grade I esophageal varices and a small segment of columnar epithelium on a variceal segment. Biopsy results were positive for BE with low grade dysplasia. The patient was started on a proton pump inhibitor and scheduled for follow-up. Patient was placed under surveillance with annual EGD. Frequent discussions were held regarding the risks vs benefits of the different treatment options. Next endoscopy revealed progression of his EV to grade II and a persistent area of columnar epithelium on one of the varices. A decision was made to band 2 varices, including the one with Barrett’s epithelium. Repeat endoscopy one year later demonstrated complete resolution of both, the varix and the columnar epithelium. Biopsy was negative for dysplasia and metaplasia. Ten years later, with yearly follow-up, endoscopy continues to be unremarkable in the banded segment. DISCUSSION: Epidemiology of BE and its relationship with adenocarcinoma has been extensively described in literature, however it is unknown what percentage of these patients have underlying liver cirrhosis with complications such as EV. This maybe be due to decreased life expectancy of these patients and the lack of routine endoscopic screening.We expect to face more of these challenging cases due to improved life expectancy of cirrhotic patients and the more readily available screening, such as endoscopic procedures for esophageal varices. Our case presents a novel method of treating this unique and difficult clinical scenario. However, we need more cases to validate our work.

1144 A Prospective Study on PPI Response in Children With Eosinophilic Esophagitis

INTRODUCTION: Proton pump inhibitors (PPIs) are now considered a treatment option for eosinophilic esophagitis (EoE). High-dose PPI (HDPPI) response rates are 23-63% in pediatric studies. Our primary aim was to determine PPI response rate in children with EoE. Secondary aim was to determine clinical, endoscopic, or histologic characteristics that impact this PPI response. METHODS: A prospective cohort study of children was conducted. Demographics, clinical history, child and parent-proxy Pediatric EoE Symptom Scores version 2 (PEESSv2.0), EoE endoscopic reference scores (EREFS), and histology scores were collected at endoscopies before and after at least 8 weeks of HDPPI. EoE was defined as ≥ 15 eosinophils/high powered field (eos/hpf) on biopsy from any level of the esophagus on initial endoscopy with symptoms of esophageal dysfunction. Children with &lt; 15 eos/hpf on repeat endoscopy were classified as PPI-responsive (PPI-R) EoE, and ≥ 15 eos/hpf were classified as PPI-nonresponsive (PPI-NR) EoE. RESULTS: 72 children were enrolled from 2015 to 2018 (58% male; mean 9.4 years). 40 children (56%) met criteria for EoE, and 25 had endoscopies before and after HDPPI. 11 refused HDPPI, and 4 were lost to follow-up. 32% (8/25) of children had PPI-R EoE. Baseline demographics, clinical history, child and parent-proxy PEESSv2.0 scores, parent-proxy dysphagia subdomain scores, EREFS, and histology scores were similar in PPI-R and PPI-NR EoE patients. Baseline child dysphagia scores were worse in PPI-NR EoE patients than in PPI-R EoE patients (17.8 v 11.0, P = 0.012). Parent-proxy PEESSv2.0 scores improved in PPI-R and PPI-NR EoE groups after HDPPI (P = 0.046, P = 0.005). Child PEESSv2.0 scores, and parent-proxy and child dysphagia scores improved significantly in the PPI-NR group after HDPPI (33.2 to 19.1, P = 0.006; 18.9 to 8.9, P = 0.004; 17.8 to 9.2, P &lt; 0.001). EREFS improved in PPI-R and PPI-NR EoE groups (P &lt; 0.001, P = 0.030), but had more improvement in the PPI-R group (P = 0.017). Children in the PPI-R group had improvement in degranulation and basal cell hyperplasia compared to the PPI-NR group (P = 0.016, P = 0.008). CONCLUSION: 32% of children with EoE responded to HDPPI therapy. No characteristics predicted PPI response. As anticipated, endoscopic and histologic features of EoE improved more in the PPI-R group. We did not expect to find that child and parent-proxy symptom scores would improve significantly in the PPI-NR group. The value of these symptom scores and their role in EoE management should be further studied.

3100 Acute Esophageal Necrosis (Gurvits Syndrome) in a 78-Year-Old Male Filipino Patient

INTRODUCTION: Acute Esophageal Necrosis (AEN), also known as Gurvits Syndrome and commonly referred to as Black Esophagus, is a rare life-threatening clinical entity with an estimated prevalence of 1 to 200 in 100,000 and a mortality rate of approximately 30%. Only 88 patients over a span of 40 years have been reported. It is associated with geriatric males, diabetes mellitus, GERD, CKD, hypertension, vascular disease, alcohol abuse, malnourishment, ingestion of caustic agents and some medications. These factors predispose a patient to AEN through hemodynamic compromise, low-flow states, tissue hypoperfusion, corrosive injury and diminished mucosal defenses. Upper GI bleeding is the presenting complaint in around 90% of cases. It is diagnosed on endoscopy where characteristically, a diffuse, circumferential, necrotic esophageal mucosa is seen. The treatment for AEN aims to address the underlying medical illness, maintain and restore hemodynamic stability with intravenous fluid resuscitation and blood transfusions, attain complete esophageal rest, gastric acid suppression and antimicrobials. CASE DESCRIPTION/METHODS: A 78-year-old Filipino man developed hematemesis on a background of T2DM, hypertension, NSAID use and excessive alcohol use. He had no GI signs or symptoms prior to this episode. Four hours later he became drowsy and confused and was noted to be in hyperosmolar hyperglycemic state. An endoscopy revealed a distinctly diffuse circumferential necrosis of the esophagus with abrupt demarcation at the gastroesophageal junction. The gastric mucosa and biopsies were unremarkable. CT showed a distended aperistaltic esophagus with circumferential thickening with no evidence of perforation. Post endoscopy he was treated in ICU where he was maintained on parenteral nutrition, meropenem, nystatin, pantoprazole and insulin. Repeat endoscopy 7 days later showed pink mucosa after appropriate glycemic control, bowel rest and hemodynamic stabilization. He was discharged 3 days later. DISCUSSION: This is the first known report of a Filipino diagnosed with AEN. He presented with hematemesis, many of the risk factors associated with AEN, and his endoscopic findings were classic for AEN. However, he was only diagnosed sometime after endoscopy. This case highlights that AEN may be underdiagnosed and that clinicians should be mindful of it as populations develop more co-morbidities and risk factors that predispose them to developing it. This case also highlights the reversibility of this life-threatening condition.

3007 Santorinirrhage Due to Hemosuccus Pancreaticus as a Rare Manifestation of Upper Gastrointestinal Bleeding

INTRODUCTION: Hemosuccus pancreaticus (HP), bleeding from the pancreatic duct into the gastrointestinal (GI) tract via ampulla of vater, is extremely rare. Some causes include pancreatitis, pseudoaneurysm of the peri-pancreatic vessels, or malignancy. The rarity with which this condition is encountered makes HP difficult to diagnose. We present a case of HP with bleeding from the minor duodenal papilla from a pancreatic pseudocyst. CASE DESCRIPTION/METHODS: A 39-year-old male with alcohol use disorder and chronic pancreatitis presented to the hospital with complaints of abdominal pain and melena. Labs showed significant anemia: hemoglobin, 6.90 g/dL. He was admitted for blood transfusions and further investigation. Endoscopic evaluation showed portal hypertension gastropathy, without evidence of gross bleeding. CT abdominal scan showed cystic lesions at the pancreatic tail and within the pancreatic body (Figure 1). Endoscopic ultrasound fine needle aspiration biopsy of the cystic lesion was done. Fluid analysis was consistent with pancreatic pseudocyst with elevated amylase. He was discharged home in stable condition with gastroenterology follow-up. He returned to the hospital with recurrent episodes of melena and transfusion-dependent anemia. He had IR guided transjugular intrahepatic portosystemic shunt from right hepatic vein to right portal vein. He continued to have episodes of melena with new coffee-ground hematemesis. Repeat endoscopy was performed with frank bleeding noted from the minor duodenal papilla (Figure 2). MRI was unable to confirm pancreas divisum due to pancreatic atrophy and poor visualization of the pancreatic duct. CT abdominal scan now showed hemorrhage within the two pancreatic cysts. Mesenteric angiogram was performed which showed pseudoaneurysm off proximal splenic artery and gastroepiploic artery both of which were embolized (Figure 3). His abdominal distension and pain improved significantly after the procedure with no more episodes of melena or hematemesis. He was discharged home without recurrence of symptoms. DISCUSSION: Our case illustrates the diagnostic dilemma of obscure upper GI bleeding. HP with bleeding from the duct of Santorini has been reported twice. All hemodynamically stable patients with HP should undergo endoscopic, radiographic, and angiographic evaluation. Therapeutic options consist of selective embolization or surgery. A multidisciplinary team approach with a precise protocol is paramount to drastically reduce the mortality and morbidity of patients.

617 Outcomes of Patients With Small Bowel Angiodysplasia Treated With a Small Bowel Radiofrequency Ablation Catheter: A Multicenter Case Series

INTRODUCTION: Small bowel angioectasia (SBA) are the most common cause of small bowel GI bleeding, usually treated with argon plasma coagulation (APC). Bleeding recurs in &gt;40%. The outcomes of patients with SBA treated with a dedicated radiofrequency ablation catheter was reported. METHODS: Patients were treated using a commercially available small bowel radiofrequency ablation catheter (SBRFA) during enteroscopy which is 25 mm wide, 260 cm long, and the treatment paddle is 7.5 mm wide deployed, and 10 mm long. The paddle was advanced to the lesion, and gentle pressure was applied delivering 10 J/cm2 with each application. The same area could be treated twice. Patient demographics, pre and post treatment hemoglobin, time to recurrent bleeding, and need for repeated therapy were reported. RESULTS: 20 subjects were treated from March to October 2018: 6 females (age 68; SD 11.1) and 14 males (age 73; SD 10.4). Three subjects had a left ventricular assist device (LVAD). 19 (95%) had at least one previous EGD (total at least 43, range 1 to &gt;10), and at least one previous colonoscopy (total 42, range 1 to &gt;10). 14 subjects (70%) had an abnormal video capsule endoscopy; 14 (70%) had previous APC. Median hemoglobin before treatment was 8.3 g/dL (5.1-14.4), and 13 subjects (65%) had a mean of 4 (SD 2.1) units of blood transfused. A median of 23 SBA were treated (2 to 99 total). No other treatments such as APC were used. Median follow-up was 195 days (30-240). The most recent median hemoglobin in 15 subjects (75%) was 9.4 g/dL (5 to 13) (P = 0.04). Repeat endoscopy rate was 20%; once in 2 subjects (at 45 and 210 days after SBRFA), and twice in one subject (60 days after SBRFA treatment). One subject with LVAD had a repeat upper endoscopy and no treatment, one subject with GAVE had a push enteroscopy and no treatment, and the third subject with LVAD had two assisted enteroscopies: SBA were re-treated with APC once, and no treatment was needed the last time. One patient with an LVAD had overt ileum bleeding and underwent embolization. 2 subjects (10%) required repeat blood transfusion (2 units each). Two deaths at 60 and 180 days were unrelated to GIB. CONCLUSION: In this series of SBRFA therapy of SBA up to 240 days of follow up 3/20 subjects (15%) required repeat endoscopy. Repeated endotherapy was necessary in 1 subject. All subjects with LVAD had repeat procedures. 2 subjects required more blood transfusions. The data compares favorably to historical SBA outcomes but comparative studies are needed.

3033 Acute Pancreatitis Complicated by Pancreatic Pseudocyst and Splenic Hematoma, Management Considerations

INTRODUCTION: Pancreatic duct disruption is a known complication of pancreatitis which leads to the formation of pancreatic pseudocysts, pancreatic ascites, and high amylase pleural effusions. Pancreatic pseudocysts migrate along with the pancreatic tissue and rupture either into surrounding organs or into the free peritoneal cavity. Splenic complications of pancreatitis are rare and include splenic vein thrombosis, splenic artery rupture, splenic rupture or infarction, and splenic hematoma. CASE DESCRIPTION/METHODS: 39 y/o alcoholic male admitted for acute pancreatitis. Imaging revealed pseudocysts and ascites. Initially, he improved with supportive care but abdominal pain recurred owing to splenic rupture with resultant splenic hematoma. Splenic artery coiling was employed to stop bleeding. He returned for recurrent abdominal pain and new chest pain with interval increase in size of pseudocyst and interval development of pleural effusion. EUS revealed a multiloculated pancreatic pseudocyst, as well as pancreatic duct disruption. Transgastric drainage of the pseudocyst was performed with an Axios stent. Repeat endoscopy at interval showed complete resolution of the cyst. DISCUSSION: Studies estimate the incidence of pancreatic pseudocyst rupture into the spleen at a rate of up to 1.1% of patients with acute pancreatitis. Another study of patients with chronic pancreatitis reports splenic pseudocyst as the most common lesion, followed by splenic rupture and hematoma. A more recent study of 500 men with chronic alcoholic pancreatitis found that only 2.2% develop splenic complications with intrasplenic pseudocyst being the most common lesion, followed by splenic rupture and subcapsular hematoma. Findings associated with the highest risk of developing splenic complications included pancreatic tail necrosis, distal pseudocyst, or splenic vein occlusion. Previously, the mainstay of treatment for splenic hematoma was splenectomy with distal pancreatectomy. However, with the advent of advanced endoscopic procedures, patients are safely managed with splenic artery embolizationand EUS guided pancreaticogastrostomy or percutaneous drainage. Endoscopic drainage and percutaneous drainage of symptomatic pseudocysts are preferred to surgical management. Furthermore, recent reviews show that endoscopic drainage is superior to percutaneous drainage with lower rates of reintervention, shorter hospital stays, and need for less follow-up imaging.

1712 Detection of Sub-Surface High-Grade Dysplasia Following Radiofrequency Ablation (RFA) of Barrett’s Esophagus

INTRODUCTION: Barrett's esophagus (BE) occurs when intestinal epithelium replaces squamous epithelium normally lining the distal esophagus. BE is associated with an increased risk of esophageal adenocarcinoma (EAC). While traditionally associated with Caucasian males, prevalence of BE and EAC in Asian populations is projected to rise, associated with increasing prevalence of gastroesophageal reflux disease (GERD), which is associated with obesity and hiatal hernia. Radiofrequency ablation (RFA) is an endoscopic treatment modality shown to be safe and effective in inducing reversion to squamous epithelium, with a treatment depth of 500-1000 microns. We present a case of BE with high-grade dysplasia identified on random forceps biopsy after RFA for BE with low grade dysplasia, after which significant sub-surface disease was detected by volumetric laser endomicroscopy (VLE). CASE DESCRIPTION/METHODS: A 72 yo Chinese male was diagnosed with short-segment BE containing low grade dysplasia, and was treated with 2 sessions of focal RFA 5 months apart. He was lost to follow up and re-established care two years later. At presentation, the patient denied any heartburn, dysphagia or weight loss. Surveillance endoscopy with white light and narrow band imaging (Figure 1) revealed short tongues of salmon-colored mucosa suspicious for residual BE. Forceps biopsy confirmed BE with high grade dysplasia at the 12:00 position. Repeat endoscopy using VLE demonstrated suspicious-appearing glands, primarily sub-surface, which were laser marked and resected with band ligation and snare instead of forceps biopsy (Figure 2). Pathology results confirmed high-grade dysplasia within BE (Figure 3). Due to the presence of dysplasia deeper into the epithelium, in the setting of prior RFA, the patient was referred for liquid nitrogen spray cryotherapy. DISCUSSION: Residual or recurrent BE following RFA is a relatively common finding, but it is uncommon to see disease with a higher dysplasia grade than what was found pre-treatment. In this case, the use of VLE to evaluate these findings identified deeper disease that may not have been amenable to initial RFA treatment, with the lesion becoming “buried” after incomplete ablation. VLE, which visualizes the esophageal wall to a depth of 3 mm, should be considered as part of the evaluation of residual BE, especially when dysplasia is present. Its use may improve patient outcomes by leading to an alternate approach to both tissue sampling and further treatment selection.

1702 Acute Esophageal Necrosis: A Rare Complication of Long-Standing Alcohol Abuse With Severe Hypoperfusion

INTRODUCTION: Acute Esophageal Necrosis, the “black esophagus”, is dark pigmentation of the esophagus with histologic mucosal necrosis that presents with symptoms of bleeding from the upper GI tract. AEN itself is not a poor prognostic factor. AEN in combination with multiple comorbidities raises mortality up to 32%. Risk factors include alcohol abuse, advanced age, male gender, advanced malignancies, hypertension, coronary artery disease, renal disease, and diabetes mellitus. CASE DESCRIPTION/METHODS: A 71 yr old male with medical history of CKD4, CAD, HTN, HLD, Barrett’s esophagus, ulcerative esophagitis, and alcohol use presented with hematemesis, abdominal pain, and melena that began three days prior. Patient was hypotensive and tachycardic with a hemoglobin of 4.8g/dL. Pt was administered multiple unity's of pRBCs, IV PPI, IV Octreotide, and IV fluid resuscitation. Due to hemodynamic compromise, a left IJ CVC was placed and vasopressors started. The GI team was consulted. Emergent EGD revealed circumferential esophagitis with ulcerations, adherent clots, and large areas of black mucosal discoloration. Broad spectrum antimicrobials initiated. A gastrograffin study was obtained without extravasation noted. Patient was diagnosed with pyelonephritis and transitioned to culture sensitive antimicrobial therapy; still requiring vasopressors and blood products due to multifactorial shock. Given severity of illness and grim prognosis, the patient’s family elected for comfort care. DISCUSSION: AEN is a rare condition with an etiology thought to be multifactorial-to a low flow state from watershed distribution and corrosive injury from gastric contents due to esophagogastroparesis and gastric outlet obstruction resulting in decreased function of mucosal barrier systems and impairment of repairing mechanisms. Visualization via EGD of circumferential black mucosal necrosis with an abrupt stop at the GE junction is diagnostic. If circumferential necrosis is seen, immediate withdrawal of the scope should be performed. In patients with patchy necrosis, the clinician may be able to continue with endoscopy. Treatment is supportive with IVFR, IV PPIs, blood transfusions, carafate, and most importantly treatment of the underlying disease state. Complications include esophageal perforation, mediastinal infections with abscesses, esophageal strictures, esophageal stenosis, and death. General Surgery should be consulted for possible intervention. After the patient exhibits improvement, repeat endoscopy should be performed.

2682 The Evolution and Cure of Multifocal Gastric Cancer

INTRODUCTION: Gastric cancer incidence and mortality has continued to steadily decline but remains the second leading cause of cancer death worldwide. Predominantly, gastric cancers are known to arise from a single lesion whereas gastric cancer arising from multiple lesions is uncommon. We present a case of a 67 year-old female who was initially found with gastritis in the antrum that evolved into a multifocal gastric cancer within 1 year. CASE DESCRIPTION/METHODS: The patient was a 67 year-old female who was first seen in Hepatology clinic for chronic hepatitis C with early fibrosis. After successful treatment, she underwent upper endoscopy for non-specific gastric symptoms. EGD showed gastritis in the antrum and biopsy revealed intestinal metaplasia and H-Pylori was negative so repeat endoscopy was recommended in a year. Upon returning for repeat endoscopy, evaluation revealed a small antral erosion and a raised area of erythematous mucosa in the fundus. Unexpectedly, biopsies revealed extensive intestinal metaplasia and high-grade dysplasia in both lesions. The patient was immediately referred to an academic center for upper endoscopic ultrasound and mucosal resection. Both studies were unremarkable, so the patient returned to our facility and underwent upper chromo-endoscopy. By this time, the antral erosion had markedly increased in size and became an ulcer with circumferential induration and staining centrally with methylene blue. There was also methylene blue uptake in two other erosions within the fundus. Repeat biopsy of the ulcers now showed nascent well-differentiated adenocarcinoma associated with high-grade dysplasia. Whole body computerized tomography showed no evidence of metastasis so patient underwent total gastrectomy. Surgical pathology revealed multiple foci of intestinal type gastric adenocarcinoma in the background of high-grade dysplasia and intestinal metaplasia. All lymph nodes and margins were negative. DISCUSSION: There have been less than 50 cases of multifocal gastric cancer reported in the literature with even fewer cured by total gastrectomy. Upper gastrointestinal endoscopy remains the gold standard for diagnosing gastric lesions. Generally, surveillance isn’t recommended for findings of intestinal metaplasia. However, our case serves to highlight the importance of diligent endoscopic surveillance and tissue sampling, even if findings convey low suspicion. Our patient was successfully cured of multifocal gastric cancer, a disease that usually carries a very poor prognosis.

1893 Non-Surgical Endoscopic Management of a Sealed Nail Perforation in the Gastric Antrum

INTRODUCTION: Foreign body ingestions are most commonly seen in children, elderly adults, and patients with psychiatric conditions. Perforation is a feared complication, often requiring surgical intervention. We present a case of endoscopic removal of a sealed nail perforation with an over-the-scope clip closure in a patient who was a high-risk surgical candidate. CASE DESCRIPTION/METHODS: A 48-year-old homeless male with a history of multiple abdominal surgeries due to gunshots and stab wounds complicated by abdominal hernias presented with 1 week of abdominal pain after drinking an open bottle of soda. Vital signs were stable on presentation. Labs were unremarkable. Computed tomography (CT) revealed a needle-like foreign body in the antrum of the stomach that appeared to project beyond the lumen without signs of pneumoperitoneum free perforation or fluid (Figure 1). An upper endoscopy was performed to further characterize the foreign body. Upon entering the stomach, a 2mm round metallic circular object (Figure 2) was visualized along the lesser curvature of the antrum, suggestive of a nail embedded into the gastric antrum. General surgery was consulted given concern for perforation, however, the patient was deemed a high-risk surgical candidate due to hostile abdominal scarring. The decision was made for endoscopic repair of the nail perforation. On repeat endoscopy, the nail was again visualized in the lesser curve of the antrum; rat-tooth forceps were used to remove a 2.8cm rusty nail (Figure 3) which was safely pulled through an overtube. The scope was reinserted with an over-the-scope clip attached, which was then successfully deployed at the site of perforation. Patient tolerated the procedure well with no signs of peritonitis and follow-up CT four days post-procedure showed the clip in place. DISCUSSION: Complications such as perforations and abscesses occur in less than 1% of foreign body ingestions. The most common sites of perforation are the ileocecal valve and other points of intestinal angulations. There are limited cases in the literature of endoscopic intervention in a sealed nail perforation in the stomach in an adult. We found that an over-the-scope clip was effective in sealing a small perforation without evidence of peritonitis on follow-up examinations. Coordination with the surgical service is important in endoscopic repair of perforations. Overall, endoscopic removal of a sealed nail perforation is a viable option for high-risk patients.

2146 Combined Novel Endoscopic Techniques in Esophageal Carcinoma Management

INTRODUCTION: A variety of techniques are currently being investigated to provide optimal resection of submucosal tumors by endoscopy. Specifically, peroral endoscopic myotomy (POEM) is a form of natural orifice transluminal endoscopic procedure which was originally established as a minimally invasive technique to treat achalasia and esophageal motility disorders. Due to its success in treatment of esophageal motility disorders, certain Centers of Excellence for advanced endoscopy have expanded the use of POEM in combination with other advanced endoscopic techniques for treating esophageal cancers. In this case, we present a 69-year-old male with squamous cell cancer (SCC) in the lower third of the esophagus who was successfully treated using combined endoscopic submucosal dissection (ESD), submucosal tunneling, and POEM techniques. CASE DESCRIPTION/METHODS: A 69-year-old male with a medical history of 50-pack-year tobacco abuse, chronic alcohol use, and chronic pancreatitis was initially evaluated with EGD and EUS for anorexia, weight loss, and pancreatic cysts. Initial EGD required biopsies of nodular esophageal mucosa revealing underlying squamous cell carcinoma in situ. Repeat endoscopy 2 months later revealed a large tumor circumferentially involving 80% of the lumen in the lower esophagus. Subsequently, the patient received therapeutic intervention combining ESD and POEM techniques for tumor resection, prognostication, and symptom relief. Lesion borders were marked, and a circumferential incision was made around the lesion lifting it from the muscularis propria allowing for successfully mass excision. The submucosal dissection combined with circumferential tunneling technique allowed for complete resection of the tumor. The patient reported post-procedure symptomatic relief and was able to resume oral intake. DISCUSSION: POEM is a combination of the pre-existing endoscopic myotomy procedures in conjunction with endoscopic submucosal tunneling techniques. Although POEM is labor intensive, its application gives precision by granting access to the neoplasms without affecting deeper esophageal layers. This promising advance in gastrointestinal procedures compared to esophagectomy has shown in reported studies to offer a lower morbidity rate while providing similar cancer-free survival. Our case demonstrates successful treatment using POEM and adjunct endoscopic therapies in submucosal tunneling and submucosal tunneling endoscopic resection (STER) in the treatment of large circumferential esophageal cancer.

2774 Gastritis After Combination Ipilimumab and Nivolumab: A Rare Adverse Event After Immunotherapy

INTRODUCTION: Immunotherapies are commonplace in the treatment of many neoplasms, and have an array of commonly reported toxicities. Among the reported gastrointestinal side effects, diarrhea and colitis are most frequently cited. However, there have only been a rare handful of reported cases of Immune-checkpoint modulator toxicity affecting only the upper GI tract. In this paper we report a case of Ipilimumab-Nivolumab associated Gastritis in a patient treated with these medications at our facility. CASE DESCRIPTION/METHODS: The patient is a 78-year-old male with Stage IV Melanoma who presented to the hospital with nausea, vomiting, weight loss, and reduced oral intake for two weeks. The patient had most recently received 2 rounds of Ipilimumab and Nivolumab for his Melanoma 2 weeks prior to his presentation to our hospital, concurrent with the start of his symptoms. There had been no history of NSAID usage during this time, and physical exam was notable for mild epigastric tenderness. A Computed Tomography scan of the Chest/Abdomen/Pelvis showed diffuse thickening of the stomach, compatible with gastritis. Upper Endoscopy revealed diffuse severely erythematous mucosa with bleeding on contact in the entire examined stomach, and patchy, mildly erythematous mucosa without bleeding was found in the duodenal bulb, with the second portion of the duodenum being normal. The pathology report revealed subacute gastritis with acute inflammatory exudate consistent with an area of mucosal ulceration, with other etiologies of gastritis ruled out. The patient was begun on glucocorticoid therapy, with rapid resolution of his symptoms. Repeat endoscopy 2 weeks later revealed resolution of the previously noted gastritis and inflammation. Pathologic examination of biopsies confirmed resolution of the inflammatory process. DISCUSSION: On review of the literature, gastritis resulting from immune-checkpoint modulators has rarely been reported on. Some common side effects associated with these immune modulating medications, colloquially called immune-related adverse events (irAEs), include diarrhea, colitis, and hepatitis. However, there are a few case reports concerning the development gastritis without enterocolitis after Nivolumab treatment alone. Approximately 3 case reports and 1 case series of 20 patients describe such a side effect, To date, there are no reported cases of a patient treated with both Nivolumab and Ipilimumab who developed gastritis as the only adverse event.