Repeat Endoscopy Research Articles

Eosinophilic oesophagitis and coeliac disease: is there an association?

A 25-year-old man was seen in outpatient clinic for progressive solid food dysphagia. He was already medicated with a proton pump inhibitor with no improvement. His blood tests showed a...

Prospective assessment of disease-specific quality of life in adults with eosinophilic esophagitis.

Eosinophilic esophagitis (EoE) is an important cause of upper gastrointestinal dysfunction in children and adults. The EoE-quality of life (QOL)-A was validated as a disease-specific measure of quality of life in EoE. This study characterized the extent of QOL concerns in a cohort of adult EoE patients and delineated the relationships between QOL and other disease activity measures. One hundred sixty-seven patients enrolled in this prospective cohort study. Patients with established and suspected EoE undergoing endoscopy at a single university-based medical center were recruited. EoE was diagnosed on the basis of the clinical criteria and histologic demonstration of ≥15 eos/hpf while on proton pump inhibition therapy. Sixty five patients undergoing repeat endoscopy during the enrollment period participated twice. Patients provided demographic information and completed symptom assessments and the EoE-QOL-A. Analyses included comparisons with overall QOL as well as QOL subscales. Outcome measures included endoscopic activity using a validated instrument, the EoE Endoscopic Reference Score, and histology. Overall QOL was significantly correlated with dysphagia frequency, intensity, and severity (P<0.001). Patients who experienced a food impaction in the last 30 days had significantly worse overall QOL (P=0.009). There was no correlation between overall QOL and years since diagnosis, symptom duration, endoscopic features, or histologic findings. Patient symptoms correlated with endoscopic features of edema, rings, and stricture severity. Histologic activity was highly correlated with severity of endoscopic features. Patients who underwent repeat endoscopy with histologic response demonstrated improved eating and social QOL; however, overall QOL was unchanged. In adults with EoE, patient reported QOL is associated with symptom severity but not endoscopic or histologic features. Disease-specific QOL may complement parameters of biologic activity in the assessment of overall disease burden in EoE.

Sialendoscopic Approach in Management of Juvenile Recurrent Parotitis.

retrospective study. Department of Otorhinolaryngology in tertiary care hospital. 17 cases of juvenile recurrent parotitis (i.e. children of age group 3-11years presenting with complaints of recurrent parotid region swelling and pain, sometimes associated with fever) were included in the study during October 2012-September 2015. All cases underwent sialendoscopy under general anaesthesia. Diagnostic (classifying the ductal lesion) and interventional sialendoscopic procedure (dilatation with instillation of steroid) were carried out in single sitting. Follow up was done for a minimum of 6months (range 6-36months). 17 patients with mean age of 5.6years and gender distribution of 47:53 (boys:girls) underwent sialendoscopy for JRP. 8 patients presented with unilateral parotitis and 9 with bilateral. The mean number of attacks in previous 1year were 9.2. Average time for procedure was 20min. All cases had ductal stenosis and ductal mucosa was pale in 15 cases on endoscopy. 1 patient underwent repeat endoscopy after 2years. 50% had complete resolution of symptoms and 6 patients had one mild (swelling not associated with fever which subsided on its own) attack after treatment. Follow up period ranged from 6months to 3years. No complications were observed. Sialendoscopy has emerged as a viable option for assessment and treatment of JRP. Dilatation of the parotid duct and steroid instillation has significantly reduced the morbidity of this condition.

Recurrent episodes of esophageal candidiasis without dysphagia post-Guillain-Barré syndrome: an unusual presentation of achalasia

Here, we present a case of a 50-year-old male with a history of a Guillain-Barré-syndrome, who was referred to our clinic with recurrent esophageal candidiasis and long-standing intermittent retrosternal cramps...

Risk Factors for Death in Dogs Treated for Esophageal Foreign Body Obstruction: A Retrospective Cohort Study of 222 Cases (1998-2017).

BackgroundLimited data exist describing risk factors for death, and long‐term outcomes in dogs with esophageal foreign body (EFB) obstruction.Hypothesis/ObjectivesTo evaluate short‐ and long‐term outcomes, and analyze risk factors for death in dogs with EFB obstruction. We hypothesized duration of entrapment and treatment type would affect outcome.AnimalsA total of 222 dogs were treated for EFB obstruction at an emergency and referral hospital between March 1998 and March 2017.MethodsMedical records for dogs with EFB were retrospectively evaluated.ResultsForeign material most frequently was osseous (180/222 [81%]), with distal esophagus the most common location (110/222 [49.5%]). Duration of clinical signs was not associated with risk of death (OR = 1.08, 95% CI 0.99–1.17; P = 0.2). Entrapment was treated by endoscopy (204/222 [91.8%]), surgery after endoscopic attempt (13/222 [5.9%]), and repeat endoscopy after surgery was recommended but declined (5/222 [2.3%]). In‐hospital case fatality rate was 11/222 (5%). Risk of death was significantly higher with surgery (OR = 20.1, 95% CI 3.59–112.44; P = 0.001), and 5/5 (100%) of dogs died if undergoing endoscopy after surgery was recommended but declined. Increasing numbers of postprocedural complications (OR = 3.44, CI 2.01–5.91; P < 0.001), esophageal perforation (OR = 65.47, CI 4.27–1004.15; P = 0.003), and postprocedure esophageal hemorrhage (OR = 11.81, CI 1.19–116.77; P = 0.04) increased in‐hospital risk of death. Esophageal strictures were reported in 4/189 (2.1%) of survivors available for follow‐up.Conclusions and Clinical ImportanceDeath is uncommon in canine EFB; however, treatment type affects outcome, and these data should be used to guide decision‐making in dogs with EFB.

A Case of GIST Bleed: A Challenging Endoscopic Diagnosis

Gastrointestinal stromal tumors (GIST) are the most common type of mesenchymal tumor of the gastrointestinal (GI) tract, yet account for < 1% of all GI tumors. GISTs can be asymptomatic, making them challenging to diagnose. We present a case of a young man with a GI bleed, thought to be caused by duodenal ulcer. On repeat endoscopy, the ulceration was actually part of a protruding mass. A 29-year-old Singaporean man presented to an outpatient clinic with a week of fatigue, tarry stool, and was found to be anemic with a hemoglobin of 7 g/dL. Esophagogastroduodenoscopy (EGD) revealed a non-bleeding 40 mm ulcer with adherent clot in the second part of the duodenum which was injected with epinephrine and and clipped with four hemostatic clips (Figure 1). A second EGD was performed 2 days later which revealed intact clips, however the ulcer appeared to be part of a submucosal mass (Figure 2. 3). Stomach biopsies showed mild chronic gastritis, negative for H. pylori but no biopsy of the ulcer was taken due to its necrotic appearance. No lesion was identifiable via CT enterography. Laparoscopic exploration yielded resection of a 2.8 x 2.7 x 2.5 cm submucosal mass. Pathology was CD117 and CD34 positive, confirming the diagnosis of a GIST, and the patient was referred to oncology. GISTs often occur in older males, with a higher incidence in increasing age. Their immunohistochemistry is commonly positive for protooncogene c-kit (CD117), a receptor tyrosine kinase (RTK) protein which is not seen in other neoplasms of the GI tract [1]. Chemotherapy targeting RTK, such as imatinib and sunitinib, has shown efficiacy in GISTs. Despite the efficacy of RTK inhibitors, definitive management of GISTs involves surgical interventation. The National Comprehensive Cancer Network recommends resection of masses ≥ 2 cm and close surveillance for smaller tumors without high risk features [2]. Adjuvant chemotherapy with imatinib for at least 3 years to decreases the risk of recurrence, as all GISTs are considered malignant with potential to metastasize. The challenging nature of their diagnosis, management, and risks illustrates the importance of maintaining a high clinical suspicion of GISTs.Figure: Ulcer at presentation and after intervention.Figure: At repeat endoscopy.Figure: At repeat endoscopy following intervention.

Effect of Outpatient Status on Practice Management of H. pylori-associated Peptic Ulcer Disease

Introduction:Helicobacter pylori infection remains an important cause of peptic ulcer disease (PUD). The 2007 and updated 2017 American College of Gastroenterology guidelines indicate that patients with H. pylori-associated PUD should receive eradication therapy followed by confirmation testing to prove H. pylori eradication. The latter is relevant because initial H. pylori treatment is often only 70-85% successful and persistent H. pylori infection may be associated with recurrent ulcers and gastric malignancy. Despite guidelines, confirmation testing rates are modest (30-40%) for largely unexplored reasons. The aim was to identify barriers and predictors of receiving guideline-concordant confirmation testing. Methods: We performed a retrospective cohort study of patients with active H. pylori-associated PUD diagnosed in 2007-2015, who received standard eradication therapy and had follow-up within one year. Our primary outcome of interest was the effect of outpatient vs. inpatient status (at time of peptic ulcer diagnosis) on confirmation testing rates. We also compared confirmation testing rates in patients with vs. without repeat endoscopy and patients with vs. without gastroenterology follow-up. We used logistic regression models with propensity scores to control for age, sex, race, comorbidity status, insurance status, ulcer location and symptom persistence. Results: 67/152 (44%) patients received guideline-concordant confirmation testing. Outpatients (OR 3.9, 95% CI 1.8-8.8, p=0.0009) and patients who had gastroenterology follow-up (OR 9.7, 95% CI 3.2-29.0, p=0.0009) were significantly more likely to receive confirmation testing than their counterparts (Table 1). Repeat endoscopy was not a significant independent predictor of receiving confirmation testing.Table: Table. Independent predictors of receiving confirmation testing to prove H. pylori eradication in patients with H. pylori-associated peptic ulcer diseaseConclusion: This study provides some insight into the discrepancy between recommended and practiced management of H. pylori-associated PUD following eradication therapy. We identified outpatient status and gastroenterology follow-up as independent predictors of receiving guideline-concordant confirmation testing. These findings suggest a potential role for quality improvement initiatives, particularly during the transition of care from inpatient to outpatient setting, in order to optimize adherence to best practices.

Embolization Coil Migration into Duodenum

Endoscopic hemostatis is the initial treatment modality for non variceal upper gastrointestinal bleeding. 5-10% of patients require surgery or interventional endovascular embolization therapy for massive bleeding refractory to endoscopic management. Coil migration is a rare but serious complication of embolization procedure. We report a case of gastro duodenal artery (GDA) coil migration causing duodenal perforation. A 69-year old male presented to emergency department with multiple episodes of melena and hematochezia. He was tachycardic and hypotensive on initial presentation, laboratory workup showed drop in hemoglobin from baseline of 12 gm/dl to 5.5 gm/dl. Emergent upper endoscopy showed a 2 cm ulcer in the duodenal bulb covered with fresh clot. The clot was removed with roth net. Active spurting was noticed from the artery in the ulcer base. It was injected with epinephrine and 2 hemo-clips were applied without achieving hemostasis. The continued bleeding obscured any further visualization. Thereafter emergent super selective catheterization of gastro-duodenal artery (GDA) was performed by intervention radiology. It showed pseudo aneurysm of GDA with active extravasation of contrast into duodenum. Multiple micro coils were introduced resulting in complete occlusion of GDA and pseudo aneurysm. Repeat endoscopy was performed after 4 weeks. It showed GDA coil protruding through the duodenal wall into the duodenal bulb (Panel A). CT scan of abdomen showed coil present in the GDA partially protruding into duodenal lumen without peritoneal perforation (Panel B). Patient is currently asymptomatic. Arterial embolization is considered as the gold standard for acute non variceal upper gastrointestinal bleeding refractory to endoscopy. There are no absolute contraindications to embolization because it may be needed as lifesaving procedure. It is generally considered safe because of rich collateral supply to the stomach and duodenum, however there is increased risk of infarction in patients with previous surgeries in these areas. Access site hematoma, pseudo aneurysms, arterial dissection, perforation, contrast allergy and nephrotoxicity can occur as in other endovascular procedures. Coil migration is a rare and remote complication of endovascular embolization. It can be potentially fatal due to formation of aorto-enteric fistulas.Figure: (Panel A) Embolization coil in the duodenum bulb.Figure: CT scan showing embolization coil in GDA and duodenum.

Novel Use for Maloney Dilators in the Management of Gastrostomy Stenosis

One of the most common complications of gastrostomy tube (g-tube) placement is dislodgement. Once the tube is dislodged, the stomal tract begins to close immediately as the area heals via secondary intention. Caretakers can place a small catheter into the gastrostomy to prevent complete closure but the stoma often becomes stenosed. In patients who develop stenosis, there are limited data available describing techniques to reestablish the gastrostomy tract for use. Described here is a novel technique using Maloney dilators to dilate gastrostomies. Case A 68 year old male with progressive multiple sclerosis and dysphagia presented for follow up after g-tube dislodgement and placement of a 14 Fr catheter into the stoma. Bedside exchange to a 20 Fr g-tube was unsuccessful due to stenosis. An 18 Fr g-tube was passed with moderate resistance. Days later, the patient presented with tube malfunction. The tube was found to be clogged by medications. It was determined that an 18 Fr was too small for his medications. At bedside, the 18 Fr g-tube was removed and then, starting with an 18 Fr Maloney dilator, the patient's ostomy site was dilated up to 26 Fr (Fig 1, 2). A 22 Fr g-tube was then placed without complications and utilized successfully by the patient in the following months.Figure: Small gastrostomy tube removed and Maloney dilator being lubricated prior to insertion.Figure: Maloney dilator inserted to maximal diameter.Case B 50 year old male with history of hemorrhagic CVAs with dysphagia had a 20 Fr g- tube that was dislodged and replaced with a 16 Fr catheter to prevent closure. New g-tube could not be placed as ostomy had stenosed. The ostomy was dilated using a Savary dilator and a 18 Fr g-tube was be placed. Within that same year, while attempting to replace the g-tube, a 18 Fr replacement could not be placed due to stenosis. Maloney dilators were used to dilate to 22 Fr. An 18 Fr g-tube was then placed without complications. In follow up, patient required repeat dilation after dislodgement and insertion of a 14 Fr catheter into his stoma. Subsequent dilation to 24 Fr with Maloney dilators was well tolerated. Patient required no further dilations over the following 5 year period. When gastromy stomas become stenosed, Maloney dilators can be safely used to dilate to a desired size. Without the need for wires or other devices, this can be done by a single provider and saves the patient from repeat endoscopic placement. This method is also more cost effective than other dilation methods and repeat endoscopy. This should only be attempted in patients with mature stomal tracts.

Clinical Utility of Rectal Endoscopic Ultrasound in Evaluation of Sub-centimeter Rectal Carcinoid Tumors

Introduction: Rectal carcinoid tumors are often small and asymptomatic, usually diagnosed during screening colonoscopy, and up to 85% are localized at diagnosis. Lesions smaller than 1 cm are rarely metastatic, yet endoscopic ultrasound (EUS) is still commonly utilized to assess tumor depth and lymphadenopathy. EUS for sub-centimeter rectal carcinoid tumors may be exposing the patient to excess testing. Methods: All patients who underwent rectal EUS at our center from December 2013 to January 2017 were reviewed, and included if they had prior endoscopy demonstrating a nodule estimated to be 1 cm or less, with pathologic confirmation of carcinoid. There were no exclusion criteria beyond this. Pathology results, endoscopy results, adverse events, and repeat endoscopy results were reviewed. Results: 85 patients had rectal EUS, 23 for rectal carcinoid. Of these, 18 had initial nodules of 1 cm or smaller. Seventeen were found on screening colonoscopy, and one on colonoscopy for lower GI bleed. Rectal EUS was performed on average 47 days after initial procedure. No tumors were poorly differentiated. Average initial size estimation was 0.62 cm. EUS detected residual tumor on 3 of 18 (16.7%) cases, though biopsy or EMR of the area of initial lesion revealed residual tumor in 5 of 18 (27.8%). No lymphadenopathy was seen, and only one case had extension of tumor into submucosa, with pathology from EMR demonstrating negative margins. There were no adverse events due to the EUS procedure, though one patient had post-procedural bleeding requiring repeat endoscopy following EMR. Seven patients had follow up endoscopy within our system, with no recurrent disease. Conclusion: EUS is typically done for evaluation of rectal carcinoid tumors, though the data to support its use in small tumors is lacking. Although rectal EUS is regarded as a low-risk procedure, there are medical risks and financial implications to its performance. We have demonstrated that in our cohort, EUS prior to biopsy or EMR of the site of rectal carcinoid does not change management. Our study does have limitations in that it is a small, single center descriptive study. Additionally, due to the referral nature of our practice, follow up data is not available for over half of the patients, meaning we may not be capturing patients with recurrent disease. Despite this, our data suggest that EUS may be unnecessary for small rectal carcinoid tumors.

A Black Esophagus

A 54-year-old woman with type II diabetes mellitus presented with a 3-day history of vomiting and mild abdominal pain. She was afebrile, tachycardic and severely hypertensive. Her abdomen was non-tender and without guarding. Laboratory evaluation revealed hyperglycemia, acidosis, acute kidney injury and elevated troponin. She was admitted with a diagnosis of diabetic ketoacidosis and hypertensive emergency. Overnight, she developed melena. Upper endoscopy revealed an esophagus with black necrotic tissue from 23cm to 32cm from the incisors, ending abruptly at the gastroesophageal junction. The patient was kept nothing per mouth and started on intravenous pantoprazole. Repeat endoscopy 6 days later showed healing of the esophageal necrosis and ulceration. Her diet was advanced, and she was switched to oral pantoprazole. Two weeks later, repeat endoscopy revealed LA class D esophagitis, which appeared substantially improved. Acute esophageal necrosis (AEN) is a rare condition with prevalence between 0.001 to 0.2%. It is characterized by circumferential black mucosa in the esophagus. It most commonly manifests as upper gastrointestinal bleeding, but it can also cause dysphagia, chest pain, or epigastric pain. Risk factors include male sex, age, cardiovascular disease, hemodynamic compromise, gastric outlet obstruction, alcohol ingestion, malnutrition, diabetes, renal insufficiency, hypoxemia, and hypercoagulable state. Diagnosis is based on the findings of upper endoscopy with the appearance of black necrotic tissue, mostly in the distal esophagus, and terminates at the gastroesophageal junction. Histology is not required for diagnosis, but it can be helpful to rule out other causes. Etiology is multifactorial, including tissue hypoperfusion due to an ischemic insult, impaired local barrier defenses, and acid reflux. Management is conservative with bowel rest, acid suppression, and hydration with restoring hemodynamic stability. Treating the coexisting medical condition is crucial, as AEN has been associated with different medical conditions, including diabetic ketoacidosis. Complications include esophageal stricture, mediastinitis, infection or abscess, and esophageal perforation. Death has been reported, with a mortality rate of 6% due to AEN, and as high as 32% due to the underlying medical condition. Therefore, high clinical suspicion and appropriate diagnosis and management are important to save the patient's life.FigureFigureFigure

Endoscopic Suturing of the Gastric Pylorus to Delay Gastric Emptying and Treat Obesity: A Pilot Study in Obese Patients: 2017 Presidential Poster Award

Introduction: Obesity is increasingly in prevalence in the United States and is commonly associated with many serious medical conditions including cardiovascular disease, diabetes, hypertension, osteoarthritis and sleep apnea. The primary treatment objective for obese patients is weight reduction. Even moderate weight loss produces significant health benefits and has been associated with marked reductions in the health risk. Methods: We enrolled consecutive patients who were referred for endoscopic therapeutic procedures for the treatment of obesity. A total of 7 patients were enrolled. Patient's weight and BMI were measured preprocedure and repeated every 4 weeks post-procedure for a total duration of 24 weeks. A gastric emptying scan was also performed prior to and 4 weeks after the suturing procedure. Steps of suturing procedure: An endoscope with a mounted suturing device (Apollo OverStitch) was advanced through an over-tube to the pylorus. One to two sutures were placed at the 2 O'clock and 4 O'clock position to narrow the pylorus by approximately 50%. The sutures are secured using suture anchors. EndoFLIP® was used just before and immediately after the procedure to measure the change in pyloric cross sectional surface area (CSA). Results: There was a significant decrease in weight (223.71lbs±13.69, 216.57lbs±13.88 p=0.01) and BMI (36.80±1.91, 35.50 ± 2.05, p=0.003) at 4 weeks. There was a significant decrease in CSA of the pylorus immediately after the pyloric suturing procedure (258mm2 ±16, 80.93 mm2 ±4.43, p < 0.001). There was a significant decrease in gastric emptying at 2 hours pre and post pyloric suturing (30.97±2.87, 47.47±7.38, p < 0.049). However, upon repeat endoscopy at 12 weeks the sutures were no longer in place and the CSA of the pylorus had returned to the preprocedure values. After 4 weeks, subjects started to regain weight; both weight and BMI returned towards preprocedure values. The study was terminated prior to full enrollment because of the lack of observed durability. Conclusion: The concept of pyloric suturing to narrow the pylorus to treat obesity is a novel and effective therapy. However, due to technical limitations (suture anchors can hold only up to 4 pounds and appear to let go over time) the sutures pulled out of the pyloric muscle after 4 weeks. We anticipate that changing the suture anchor, may allow for long term durability.

A Rare Case of Cronkhite-Canada Syndrome

Introduction: Cronkhite-Canada Syndrome (CCS) is a rare non-hereditary polyposis condition with unclear etiology. Estimated incidence is 1 case per million population. Symptoms include diarrhea, anorexia, and weight loss. Dermatologic changes are alopecia, onychodystrophy, and cutaneous hyperpigmentation. Classic endoscopic features include diffuse polyposis which spares the esophagus. Case: 71 yo M with irritable bowel syndrome, diabetes, atrial fibrillation on warfarin presented with abdominal pain, constipation and diarrhea. Gastroscopy and colonoscopy revealed inactive gastritis and two diminutive adenomatous polyps; no microscopic colitis. Over the course of five months diarrhea worsened, he developed dysgeusia and anorexia with a 25 lb weight loss. Exam: hair loss and dystrophic fingernails (Fig 1). Labs: low ferritin, hemoglobin, protein, and albumin. Stool guaic positive. Repeat EGD showed many antral polyps (Fig 2); histology: foveolar hyperplasia and chronic gastritis. Repeat colonoscopy showed many polyps throughout the colon (Fig 3) and terminal ileum; histology: chronic lamina propria inflammation and cystically dilated crypts and glands. Patient diagnosed with CCS. Weight improving on dietary supplements; symptoms are controlled with loperamide and simethicone. He declines steroids.FigureFigureFigureDiscussion: Hallmark features of CCS include diffuse polyps which are usually inflammatory, hyperplastic or juvenile but can be adenomatous. Histology is often non-specific and includes mixed inflammation, expanded lamina propia, cystic dilation of glands and crypts, and villous atrophy. Our patient had no signs of polyposis on recent EGD or nail changes on prior exams. Over 1 year, he developed non-specific symptoms that were unified by diffuse polyposis seen on repeat endoscopy. His disease onset is similar to the relatively acute onset described in the literature. Complications include malabsorption, gastrointestinal bleeding, small bowel obstruction, congestive heart failure, and sepsis. CCS has an increased risk of colon cancer. It is unclear if this relates to pre-existing polyps or is sporadic. Nutrition supplementation is crucial in therapy. Glucocorticoids are the most effective current therapy. Polyp sampling has been advocated for cancer prevention. It is important to be aware of this constellation of symptoms and to refer for endoscopic evaluation. Early diagnosis is key as this rare disease is progressive and confers significant mortality.

Endoluminal Vacuum for Spontaneous Esophageal Perforation

Endoscopic endoluminal vacuum therapy is a technique that has been used traditionally for the management of surgical anastomotic leakages and perforations in the esophagus and colon. We present a case of the use of this technique in a spontaneous esophageal perforation of unknown etiology. After review of the available literature, in this video, we demonstrate the use of this technique in a novel therapy of spontaneous esophageal perforations. Patient is a 64 year old man without a significant past medical history who developed retrosternal chest pain and was found to have a spontaneous esophageal perforation that resulted in a walled off mediastinal cavity upon initial endoscopic evaluation. The cavity was filled with debris content and extensive irrigation and lavage was performed with hydrogen peroxide for further examination. To help facilitate healing, the decision was made to place an endoluminal wound vacuum. An endoluminal sponge was sutured onto a sixteen french nasogastric tube which was facilitated down the upper intestinal tract endoscopically and placed in the cavity. External suction was attached and placed at 125 mmHG on continuous suction. After 4 days, the patient had a repeat endoscopy that showed improvement in the cavity size and notable healing. A hard object was identified which was thought to be the source of the original perforation, however it was unclear the identity of this object. The sponge was downsized and replaced. A week later, the patient had a third endoscopy which demonstrated a significantly smaller cavity with healthy granulation tissue. At this time, the patient had wanted to facilitate discharge so we decided to place a fully covered esophageal stent. The patient clinically progressed well and had been tolerating a regular diet prior to discharge. Patient had a follow up endoscopy for removal of the stent and the mediastinal cavity was no longer visualized. A small outpouching remained which was closed with one hemostatic clip. The patient had been seen for follow up with stable PO tolerance and no further complications. This case helped to highlight a new therapy with a pre-existing technique for spontaneous esophageal perforations. With serial endoscopy and downsizing of the endoluminal sponge, we recognize that perforations have the ability to heal quickly and safely. This technique can be a tool to help patients avoid invasive measures to treat esophageal perforations with good endoscopic and clinical outcome. Watch the video: https://goo.gl/Nu1HDC

Nerve Block Complication: A Rare Cause of Esophageal Perforation

60 percent of esophageal perforations are iatrogenic, most of which occur during endoscopy. We describe a rare cause of iatrogenic esophageal perforation secondary to a nerve block procedure. A 57 year-old man with stage IV renal cell carcinoma, metastatic to his lungs and spine, presented after a cancer monitoring CT incidentally found a possible esophageal perforation. Importantly, two weeks prior, the patient underwent a nerve block procedure for a T5-T7 metastatic lesion that was causing neuropathic pain. The patient reported that after the procedure the back pain worsened. On presentation, he was afebrile and his labs were only significant for a leukocytosis. The esophagram did not identify a leak, however, CT chest showed a contained collection of extraluminal contrast in the mediastinum anterior to the thoracic spine related to a very small esophageal perforation. Broad spectrum antibiotics and antifungals were started. The endoscopy found a small defect that was the suspected perforation. The tear was sutured closed and a stent was placed. The patient's back pain initially improved, however, he had recurrence of his back pain 2 weeks later. Repeat CT showed extravasation of contrast tracking from the esophagus to the posterior spine making the nerve block the most likely cause of the perforation. Repeat endoscopy found the stent had dislodged and had to be replaced. While a paravertebral nerve block is considered a very safe procedure, it is important to note that esophageal perforation is a possible complication. A review of literature did not identify any other reported cases of esophageal perforation as a nerve block complication. As the medical community is looking toward non-opioid pain control methods, nerve blocks and advanced pain procedures are becoming more common. Interestingly, the initial esophagram did not identify the leak, however, esophagrams have a 10% false negative rate. This case also demonstrates that in stable patients who have a contained esophageal perforation, nonoperative management such as covered stent placement can be considered. While more robust data needs to be gathered, small case series have shown that in selected patients nonoperative management can have fewer complications.Figure: Initial CT chest with contrast showing a small contained collection posterior to the esophagus.Figure: Follow up CT after recurrence of the back pain showing collection in the posterior mediastinum and contrast tracking posterior to the spinal canal.

The Role of Wide Area Transepithelial Sampling in Screening for Esophageal Adenocarcinoma

Barrett's esophagus (BE) requires surveillance to monitor for dysplasia and esophageal adenocarcinoma. New methods have been developed to detect dysplasia and esophageal adenocarcinoma. One of these methods called the wide area trans epithelial sampling 3D brush biopsy (WATS 3D) is a computer-assisted brush-biopsy technique which uses an abrasive sampling instrument to detect dysplasia or esophageal adenocarcinoma. The aim of our case is to demonstrate the clinical utility of this tool in Barrett's surveillance. Patient is a 66 year old with a past medical history of lifelong heartburn and regurgitation. He was on Esomeprazole 20mg daily and denied family history of colon or esophageal cancer. The patient had a screening endoscopy for surveillance of BE three months ago, which showed a 3-5 cm area of full circumferential salmon colored mucosa suspicious for BE. Biopsies revealed squamocolumnar mucosa with intestinal metaplasia and focal high-grade glandular dysplasia without malignancy. Repeat endoscopy confirmed a Prague C5M5 lesion (Fig. 1). Repeat biopsies read by 2 different pathologists confirmed the diagnosis of high grade dysplasia (Fig. 2). Wide area trans epithelial sampling 3D brush biopsy was also performed at that time. The WATS pathology report stated that patient has at least high-grade dysplasia in his cytopathology and was suggestive of esophageal adenocarcinoma. Patient was successfully managed with 2 RFA ablation sessions with obliteration of the BE and replacement of the Barrett's mucosa with a neosquamous epithelium. Esophageal adenocarcinoma has a high mortality rate and a poor prognosis. As such screening for BE is critical in preventing progression. As illustrated in our case, the WATS brush biopsy addresses the sampling error inherent in random forceps biopsy testing of the esophagus. In just a few minutes, gastroenterologists can easily obtain a wide area, full-thickness transepithelial tissue sample for computer-assisted 3D laboratory analysis. The case was discussed with experts in BE and felt there was a small foci of adenocarcinoma in the setting of high grade dysplasia. Without evidence of invasion, lesion was safe to be treated with RFA. This foci of esophageal adenocarcinoma is likely missed with the traditional sampling methods. Overall, institutions should consider either adding WATS 3D as an adjunct to standard forceps biopsy or using it as primary tool for detecting dysplasia.Figure: Narrow band image of a C5M5 area of Barrett's seen on endoscopy.Figure: Few foci of highly dysplastic epithelium, seen singly and within apparent small vascular spaces, strongly suggestive of adenocarcinoma, in a background of Barrett's metaplasia.

Utility of Gastric and Duodenal Biopsies During Follow-up Endoscopy in Children With Eosinophilic Esophagitis.

Eosinophilic esophagitis (EoE) is a chronic antigen-mediated immune disorder of the esophagus. Consensus guidelines recommend obtaining esophageal, gastric, and duodenal biopsies at diagnostic endoscopy when EoE is suspected. The utility of repeated gastric and duodenal biopsies during follow-up endoscopy in patients previously diagnosed with EoE is not established. The aim of the present study was to explore the role of gastric and duodenal biopsies in children with an established diagnosis of EoE undergoing repeat endoscopy to assess histological response to treatment. Retrospective chart review of children diagnosed with EoE at a tertiary care center was conducted. A total of 160 patients with EoE with demographic clinical, endoscopic, and histological data at diagnosis and follow-up endoscopy were included. The frequency of gastric and duodenal biopsies at follow-up endoscopy with abnormal histology and their correlation to endoscopic findings was determined. At follow-up endoscopy, 83% (132/160) of patients had gastric and 74% (118/160) had duodenal biopsies. Histology was normal in 81% of gastric and 92% of duodenal biopsies. The most frequent gastric abnormalities were chemical and inactive chronic gastritis. The most frequent duodenal abnormality was villous blunting with increased intraepithelial lymphocytes. Two patients with normal gastric and duodenal histology progressed to eosinophilic gastroenteritis at follow-up endoscopy. Gastric and duodenal biopsies obtained in EoE patients during follow-up endoscopy show pathology in a minority of patients, increase costs, and may add potential risk of adverse events. Large multicenter, prospective studies of endoscopic practice during follow-up of EoE are warranted to provide evidence supporting best practices.

Variceal Tamponade: Teaching New Dogs Old Tricks! A Performance Improvement Project

Introduction: Acute esophageal variceal hemorrhage is a dreaded complication of chronic liver disease that nearly every endoscopist will encounter during their career. In the event of failed endoscopic treatment, it is vital for one to be knowledgeable on the proper use and placement of balloon tamponade as a bridge to repeat endoscopy or transjugular intrahepatic portosystemic shunt procedure. There are many obstacles that can make the use of balloon tamponade more challenging, such as maintaining the knowledge and skill for placement given rarity of use, locating all necessary required components for proper function (these are not provided from the tube manufacturer), and educating the team and ancillary staff on tube care post-placement. Our aim in this project was to standardize the balloon tamponade process by re-educating our gastroenterology providers on tube placement and developing a balloon tamponade “kit” containing all required accessories and instructions to improve the ease and safety when this emergency intervention is required. Methods: We devised a five-question pre and post-intervention survey to test our seven staff gastroenterologists and six fellows on their knowledge of locating all components of the balloon tamponade tube, details of tube placement, and post-placement tube instructions. The intervention included introduction of our new tube kit along with a one-on-one, 20-25 minute demonstration of tube assembly, placement, troubleshooting, and post tube care instructions. We then measured improvement between pre and posttest surveys using a paired t-test. Results: There was a statistically significant improvement in confidence with each tested component of our survey, as well as for the entire group of questions post-education intervention (P<0.001), see Table 1.Table: Table. Pre/Post Test SummaryConclusion: Our balloon tamponade project was a success in standardizing the use of this device. It was also effective in refreshing our providers on proper tube placement, use, and post-placement tube care. Moving forward, our institution will continue to utilize this balloon tamponade kit until newer options become standard of care. Sample size may have been a limitation in our study. In the future, we are planning to reproduce this project to include the internal medicine residents who are typically first line in acute variceal hemorrhage cases prior to gastroenterology consultation and are usually involved in tube placement.

Utility of Combined Endoscopic Therapy With Balloon Dilation and Onabotulinum Toxin A Injection in a Patient With Gastroparesis Secondary to Hypertrophic Pylorus

Introduction: Gastroparesis is a motility disorder of the gastrointestinal tract characterized by delayed gastric emptying. The diagnosis requires endoscopic evaluation to exclude mechanical obstruction and imaging; such as gastric emptying scintigraphy, to confirm delayed gastric emptying. Pharmacological therapy for gastroparesis is limited. Metoclopramide is the only FDA-approved medication with unproven long-term efficacy. Intrapyloric botulinum toxin injection is not currently a recommended treatment modality for gastroparesis. Here, we present a case with severe gastroparesis secondary to diffuse pylorospasm which improved with endoscopic botulinum toxin injection and pyloric dilation. Case report: A 70-year-old female patient with a history of asthma and a paraoesophageal hernia repair presented to our clinic for persistent nausea and vomiting. Physical examination and initial laboratory tests including complete blood counts, comprehensive metabolic panel, and thyroid function test were all unremarkable. She underwent an upper endoscopy that showed intact paraoesophageal hernia repair, normal gastric mucosa, but thickened and hypertrophied pylorus that was traversed with moderate resistance. Duodenum appeared normal. Nuclear gastric emptying scintigraphy showed markedly delayed gastric emptying with 14% gastric emptying at 4 hours. She underwent a repeat endoscopy with CRE pyloric balloon dilation from 12 mm to 15 mm, followed by intrapyloric onabotulinum toxin A injection in a 4 quadrant fashion. Her follow-up in 6 months showed a great improvement in her symptoms. Discussion: Endoscopic botulinum toxin injection has shown benefit in many gastrointestinal motility disorders, however, it is not currently recommended as a therapy for patients with gastroparesis by our gastrointestinal society. Botulinum toxin is a potent inhibitor of neuromuscular transmission and can improve spasm in tight gastrointestinal sphincters. Several open-label trials demonstrated clinical benefits of endoscopic intrapyloric botulinum toxin injection in patients with refractory gastroparesis. Herein, we describe a patient who benefited from combined therapy using balloon dilation and intrapyloric botulinum toxin injection. The therapy appeared effective and safe with no immediate or delayed complications. Further studies are needed to identify subset of patients who might benefit from combined endoscopic therapy with intrapylroic botulinum injection and balloon dilation.

Pressure Gastric Ulcer From an Over-Inflated Gastrostomy Tube Balloon: An Unusual Cause of Upper Gastrointestinal Bleeding

Percutaneous endoscopic gastrostomy (PEG) is one of the most commonly performed endoscopic procedures used for the establishment of enteral feedings in patients with dysphagia and in the elderly population with poor oral intake. Approximately 160,000-200,000 endoscopic PEG tube placement are performed each year in the United States. Despite its high success rate (>95%), major complications have been reported in 1% to 3% of cases. Endoscopically placed PEG tubes are more durable and longer lasting because an internal bumper of the tube holds the gastric wall firmly against anterior abdominal wall. This prevents easy dislodgement of the tube and minor leakage around the stoma. Dislodged endoscopic PEG tubes with a mature gastro cutaneous fistula can be replaced at the bedside with a PEG tube with a balloon. This avoids the need for a repeat endoscopy. Though cost effective the clinician should be properly trained about proper technique to avoid adverse outcomes. One such outcome is described in this case report. 80-year-old female with dementia and multiple co-morbidities presented from a nursing home with complaints of hematemesis and bleeding around PEG tube. Clinically she was noted to be tachycardic (HR 113 bpm), febrile (100.6 degrees). Blood work revealed anemia (Hgb 6.8 gm/dl) and high Blood Urea Nitrogen. On exam, a 22 Fr balloon PEG (15 cc balloon) with dried blood in and around the tubing was observed with melena on rectal exam. EGD revealed a large gastric ulcer with a visible vessel at the point of contact with an overinflated balloon. The internal balloon of the PEG tube appeared to be overinflated (at least 25 cc in a 15 cc balloon), compressing and ulcerating the stomach wall at the area of contact between the balloon and the gastric wall (Figure 1). Successful hemostasis was achieved endoscopically and a new bumper PEG tube placed under endoscopic guidance. Overinflated PEG tube balloon resulting in a large gastric pressure ulcer is an uncommon etiology of upper GI bleeding. This report can be used to emphasize the importance of following the PEG tube manufacturers recommendations and exercise proper technique and caution.Figure: Internal balloon of PEG appeared to be overinflated and compressing the stomach wall in area of ulcer.