EUS-guided jejuno-enterostomy in a patient with total gastrectomy with Roux-en-Y esophagojejunostomy to facilitate cholangioscopy with electrohydraulic lithotripsy

Video 1EUS-guided jejuno-jejunostomy in a 67-year-old male patient with total gastrectomy with Roux-en-Y esophagojejunostomy to facilitate cholangioscopy with electrohydraulic lithotripsy

When the environment and mutations affect organ systems

Atypical hemolytic uremic syndrome (aHUS) is a rare thrombotic microangiopathy (TMA) with a genetic predisposition. Like other TMAs, it presents clinically with thrombocytopenia and microangiopathic hemolytic anemia, which is accompanied by disruption of at least one organ system. We present a case of a 42-year-old female who presented with abdominal pain, nausea and vomiting. She had hemolytic anemia, thrombocytopenia and acute kidney injury suggestive of TMA.Includes bibliographical reference

Posterior reversible encephalopathy syndrome while receiving irinotecan with fluorouracil and folinic acid for metastatic gastric cancer

Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiographic syndrome with seizures, headache, altered mental status and visual disturbances. It is typically associated with posterior cerebral white matter oedema on neuroimaging. There is an increasing number of cases of PRES reported with different chemotherapeutic protocols. However, PRES is rarely reported in association with irinotecan, fluorouracil and folinic acid (FOLFIRI). We report a 28-year-old female patient with a history of Stage IV gastric cancer who presented with abdominal pain and recurrent vomiting that was thought to be related to a partial intestinal obstruction secondary to peritoneal metastasis. Eventually, she was treated with FOLFIRI. A few hours after initiation of the fluorouracil infusion in the second cycle, she developed a tonic-clonic seizure. MRI of the brain showed multiple bilatera

Comparison of clinical outcomes in traditional gastrointestinal hemorrhage work up versus direct utilization by push enteroscopy in patients with a left ventricular assist device

BACKGROUND: Patients with left ventricular assisted devices (LVADs) are at considerable risk of gastrointestinal bleeding (GIB) of about 23%. A significant portion of GIB occur in the stomach, duodenum or small intestine as compared with lower intestinal tract. A traditional work up for such patients differs between institutions but generally includes an esophagogastroduodenoscopy (EGD) and colonoscopy +/- RBC tagged scan. If the cause of GIB is not found, a capsule endoscopy or push enteroscopy (PE) is then pursued to evaluate for small intestinal bleeding, an area not accessible by other devices/ procedures including EGD and colonoscopy. The traditional approach requires considerable time and effort leading to a significant length of hospital stay. It also exposes the patient to multiple procedures with additive potential adverse effects and cost. AIM: Our goal is to compare the traditional work up/ management of GIB with an innovative approach of performing PE as the first diagnostic/therapeutic procedure to assess if the latter increases the diagnostic yield of GIB site detection with fewer procedures per hospital admission, shortens the length of hospital stay, and decreases all-cause mortality. METHODS: This is a retrospective study was performed in Henry Ford Hospital in Detroit, MI. ICD-9 and ICD-10 diagnosis codes were used to generate a list of LVAD patients who were admitted with an overt GIB or worsening anemia in the period from 1/1/2013 to 12/25/2018. Our primary outcomes were the rate of detection of GIB lesion/site and all-cause mortality. Secondary outcomes were the number of packed red blood cell (pRBC) units transfused during the hospitalization and the length of hospitalization. Chi-square, Fisher exact, paired-T tests and Pearson correlation were used for statistical analysis. The study protocol was approved by the hospital’s IRB. RESULTS: A total of 227 patients were reviewed. 89 patients were included with a mean age 61.36 years-old. The majority of patients (75.28%) were \u3e 55 years-old and 70.78% of patients were males. All patients were on anticoagulation and 53 patients were on antiplatelets as well. The patient’s prestation were as follows: 38 patients presented with melena, 11 with hematochezia, 7 with hematemesis or coffee ground emesis and 33 patients with worsening anemia without overt GIB. A total of 71 patients underwent the traditional approach at the first index endoscopy, whereas 18 patients started with PE +/- colonoscopy. The source of GIB was detected at the first index endoscopy in 51 patients (36 traditional approach and 15 in PE approach). Arteriovenous malformation was the most common lesion detected (29 patients) and the two most common sites of bleeding were gastroduodenal followed by the small bowel. Doing PE at the first index endoscopy was associated with a higher rate of GI site detection, OR 4.861 (95% CI (1.293-18.271), P = 0.012), this was true, especially when patients presented with worsening anemia without overt bleeding, OR 11.2 (95% CI (1.202-104.33), P = 0.015). There was no statistically significant difference between both approaches in terms of all-cause mortality (P = 0.163). Patients in the PE group did have a shorter hospital stay (x̅ (SD) = 10.78 (13.97) days compared to 18.8 (25.58) days for the traditional approach) with P value = 0.034. No statistically significant difference in the number of pRBC units (P = 0.121). Finally, INR value on presentation was not associated with a higher risk of all-cause mortality P = 0.905 and didn’t correlate with a statistical significance with number of pRBC units and length of stay (P = 0.839 and 0.644 respectively). CONCLUSION: PE is a safe procedure. It increases the GIB site detection and shortens the length of hospital stay when considered on the initial evaluation of LVAD patients presenting with GIB in general and worsening anemia in specific.https://scholarlycommons.henryford.com/merf2019clinres/1022/thumbnail.jp

Gastric Metastasis from Renal Cell Carcinoma, Clear Cell Type, Presenting with Gastrointestinal Bleeding

Renal cell carcinoma (RCC) accounts for 80-85% of all primary renal neoplasms. Although RCC can metastasize to any organ, gastric metastases from RCC are exceedingly rare. A 67-year-old male presented with melena and acute blood loss anemia. The patient had a history of RCC that had been treated with a radical nephrectomy. He had a recent myocardial infarction and was receiving double antiplatelet therapy. After hemodynamic stabilization, esophagogastroduodenoscopy showed a polypoid mass in the gastric fundus. The mass was excised. Histological and immunohistochemical evaluation were consistent with clear cell RCC. The polypoid lesion is consistent with a late solitary metastasis

Chronic Peri-Oral Dermatitis as the First Manifestations of Crohn\u27s Disease

Introduction: Oral manifestations have been reported in crohn’s disease (CD). The reported prevalence of these manifestations varies widely between studies, and range between 0.5%-50% in adults and 10%-80% in pediatrics. Oral manifestations of CD may coincide with the intestinal manifestations, or less commonly precede them. Aphthous ulcers, angular cheilitis, swelling of the lips and gingiva, cobblestoning of the mucosa, deep linear ulcers and periodontal disease have been reported in the literature. Case report: An 18-year-old female with no significant history presented to her primary care physician with recurrent lip swelling and dryness. She was diagnosed initially with angioedema without urticaria. History of an environmental exposure was inconsistent and testing for hereditary angioedema, including C1 esterase and C4 levels were unremarkable. She was referred to a dermatologist who diagnosed her with peri-oral dermatitis. Treatment with antihistamines, topical steroids, antifungals, antibiotics and petroleum jelly-based products were all unsuccessful. She was treated with oral prednisone for a presumed pemphigus vulgaris with a symptomatic improvement, but she did relapse two weeks after weaning steroids. Due to chronicity of symptoms, a lip biopsy was ordered and showed a psoriasiform dermatitis with a granulomatous inflammation. Direct immunofluorescent testing was unremarkable. These results were concerning for CD versus cheilitis granulomatosa. By that time, she denied gastrointestinal symptoms, weight loss or family history of inflammatory bowel disease. Further testing revealed a normal ferritin, vitamin B12, folate, antineutrophil cytoplasmic antibodies, and QuantiFERON-TB. She was referred to gastroenterology for further evaluation. An esophagogastroduodenoscopy showed a normal esophagus, stomach and examined duodenum. Biopsies from stomach and duodenum were unremarkable. A colonoscopy showed a normal examined perianal area, colon and terminal ileum. Biopsies from the left colon showed a focal active colitis, foci of neutrophilic cryptitis and focal epithelioid granuloma without dysplasia. Stains for acid fast bacilli and fungi were negative. Biopsies from the right colon and terminal ileum were unremarkable. A magnetic resonance enterography showed no evidence of an active small bowel CD. Given the early onset and wide spread distribution, the decision was to start adalimumab 40 mg subcutaneously every 2 weeks. Her oral disease improved significantly. A repeated colonoscopy with biopsies was unremarkable. Conclusion: The recognition of oral manifestations can constitute an important clue for diagnosis and management of CD, especially that an isolated oral disease is uncommon as a first presentation of the disease. Infections, nutritional deficiencies and medication side effects are important to consider as differential diagnosis.https://scholarlycommons.henryford.com/merf2019caserpt/1048/thumbnail.jp

Association of obesity with illness severity in hospitalized patients with COVID-19: A retrospective cohort study

BACKGROUND: Although recent studies have shown an association between obesity and adverse coronavirus disease 2019 (COVID-19) patient outcomes, there is a paucity in large studies focusing on hospitalized patients. We aimed to analyze outcomes associated with obesity in a large cohort of hospitalized COVID-19 patients. METHODS: We performed a retrospective study at a tertiary care health system of adult patients with COVID-19 who were admitted between March 1 and April 30, 2020. Patients were stratified by body mass index (BMI) into obese (BMI ≥ 30 kg/m 2) and non-obese (BMI \u3c 30 kg/m 2) cohorts. Primary outcomes were mortality, intensive care unit (ICU) admission, intubation, and 30-day readmission. RESULTS: A total of 1983 patients were included of whom 1031 (51.9%) had obesity and 952 (48.9%) did not have obesity. Patients with obesity were younger (P \u3c 0.001), more likely to be female (P \u3c 0.001) and African American (P \u3c 0.001) compared to patients without obesity. Multivariable logistic models adjusting for differences in age, sex, race, medical comorbidities, and treatment modalities revealed no difference in 60-day mortality and 30-day readmission between obese and non-obese groups. In these models, patients with obesity had increased odds of ICU admission (adjusted OR, 1.37; 95% CI, 1.07-1.76; P = 0.012) and intubation (adjusted OR, 1.37; 95% CI, 1.04-1.80; P = 0.026). CONCLUSIONS: Obesity in patients with COVID-19 is independently associated with increased risk for ICU admission and intubation. Recognizing that obesity impacts morbidity in this manner is crucial for appropriate management of COVID-19 patients

Risk factors associated with adenoma recurrence following cold snare endoscopic mucosal resection of polyps ≥ 20 mm: a retrospective chart review

Background and study aims: Cold snare endoscopic mucosal resection (EMR) is being increasingly utilized for non-pedunculated polyps ≥ 20 mm due to adverse events associated with use of cautery. Larger studies evaluating adenoma recurrence rate (ARR) and risk factors for recurrence following cold snare EMR of large polyps are lacking. The aim of this study was to define ARR for polyps ≥ 20 mm removed by cold snare EMR and to identify risk factors for recurrence. Patients and methods: A retrospective chart review of colon cold snare EMR procedures performed between January 2015 and July 2019 at a tertiary care medical center was performed. During this period, 310 non-pedunculated polyps ≥ 20 mm were excised using cold snare EMR with follow-up surveillance colonoscopy. Patient demographic data as well as polyp characteristics at the time of index and surveillance colonoscopy were collected and analyzed. Results: A total of 108 of 310 polyps (34.8 %) demonstrated adenoma recurrence at follow-up colonoscopy. Patients with a higher ARR were older ( P  = 0.008), had endoscopic clips placed at index procedure ( P  = 0.017), and were more likely to be Asian and African American ( P  = 0.02). ARR was higher in larger polyps ( P  \u3c 0.001), tubulovillous adenomas ( P  \u3c 0.001), and polyps with high-grade dysplasia ( P  = 0.003). Conclusions: Although cold snare EMR remains a feasible alternative to hot snare polypectomy for resection of non-pedunculated polyps ≥ 20 mm, endoscopists must also carefully consider factors associated with increased ARR when utilizing this technique

An international experience with single-operator cholangiopancreatoscopy in patients with altered anatomy

Background and study aims: The utility of digital single- operator cholangiopancreatoscopy (D-SOCP) in surgically altered anatomy (SAA) is limited. We aimed to evaluate the technical success and safety of D-SOCP in patients SAA. Patients and methods: Patients with SAA who underwent D-SOCP between February 2015 and June 2020 were retrospectively evaluated. Technical success was defined as completing the intended procedure with the use of D-SOCP. Results: Thirty-five patients underwent D-SOCP (34 D-SOC, 1 D-SOP). Bilroth II was the most common type of SAA (45.7 %), followed by Whipple reconstruction (31.4 %). Twenty-three patients (65.7 %) patients had prior failed ERCP due to the presence of complex biliary stone (52.2 %). A therapeutic duodenoscope was utilized in the majority of the cases (68.6 %), while a therapeutic gastroscope (22.7 %) or adult colonoscope (8.5 %) were used in the remaining procedures. Choledocholithiasis (61.2 %) and pancreatic duct calculi (3.2 %) were the most common indications for D-SOCP. Technical success was achieved in all 35 patients (100 %) and majority (91.4 %) requiring a single session. Complex interventions included electrohydraulic or laser lithotripsy, biliary or pancreatic stent placement, stricture dilation, and target tissue biopsies. Two mild adverse events occurred (pancreatitis and transient bacteremia). Conclusions: In SAA, D-SOCP is a safe and effective modality to diagnose and treat complex pancreatobiliary disorders, especially in cases where standard ERCP attempts may fail