Tunneled Dialysis Catheter placement induced Budd Chiari Syndrome and Cirrhosis of Liver

A 76 year old female presented with weakness and abdominal pains for 1 week. She reported two episodes of coffee ground emesis and significant amount of weight loss as well. She has a history of diabetes mellitus type 2, hypertension, end stage renal disease on hemodialysis and colonic perforation at the site of a stercoral ulcer needing left hemicolectomy and colostomy. She had a tunneled dialysis catheter placed about one year ago in her right internal jugular vein. Her vitals were stable. BMI 17.3. On physical examination, she was found to be cachectic and had tensely distended abdomen. Healthy appearing colostomy site present on abdomen as well. On laboratory evaluation, she had thrombocytopenia, elevated creatinine and elevated liver enzymes. CT scan of the abdomen and pelvis without IV or PO contrast revealed cirrhosis of the liver with moderate ascites. Paracentesis was done and 2.5 L of fluid was removed. Based on the ascitic fluid analysis, she either had Budd Chiari syndrome or Cardiac ascites. Echocardiogram revealed normal cardiac function. Upper endoscopy revealed no varices but esophagitis, gastritis and duodenitis. For evaluation of the Budd Chiari syndrome, MRI abdomen with intravenous contrast was done. It revealed partial versus complete thrombosis of the intrahepatic IVC towards the cavoatrial junction confirming Budd Chiari Syndrome. Venography revealed total complete occlusion of the IVC at the level of the diaphragm. This case raises awareness and importance of timely removal of the tunneled dialysis catheter and about its potential complication specifically Budd Chiari syndrome

It Won\u27t Pop

A 29 year old female patient presented with abdominal pains for the last 7 days. About 3 weeks ago, she had a procedure done for weight loss. In this procedure, she swallowed a pill that inflated into a balloon in the stomach. She also reported nausea and inability to eat more than a few bites. She has had about 10 pound weight loss since the gastric balloon procedure was done 3 weeks ago. Also, at the time the balloon was placed, she was also checked for helicobacter pylori and it was tested positive. She was treated with amoxicillin, clarithromycin and esomeprazole for 10 days. Eradication for helicobacter pylori had not been checked. She had no surgical history. She denied using any tobacco, alcohol or any drugs. On examination, her vitals were normal. She was alert and oriented and in no acute distress. The physical examination was within normal limits. CT scan of the abdomen with intravenous and oral contrast revealed a large and well circumscribed balloon versus cystic structure measuring 12 x 9 x 9 cm, containing mostly fluid but also a small amount of air was found. It corresponded to the finding on concurrent sonogram. There was no gastric outlet obstruction, or bowel obstruction of any kind. It was decided to keep her NPO and an EGD was scheduled for the next day. Intravenous fluids were started. Surgical consultation was requested. No immediate surgical intervention was recommended by surgical team. EGD revealed normal esophagus, intra-gastric balloon, mild gastritis and normal. Multiple maneuvers were used to deflate the balloon including puncturing with the needle to remove the fluid from the balloon and suctioning the intra-balloon fluid via the needle puncture. Significant amount of watery fluid was removed from the balloon. We tried other techniques like hot snaring, using hot biopsy forceps and cutting with cold biopsy forceps, but the material of the balloon was very slippery and none of these techniques worked. At this point, the balloon was partially deflated as the fluid was oozing out gradually. We grabbed the edge of the partially deflated balloon and attempted pulling it out however there was resistance due to the large size of the balloon. Under direct observation, we applied constant traction on the balloon by pulling it into esophagus against the GE junction and that helped deflate the balloon further into almost completely empty and it was pulled out gradually out of the stomach and esophagus by gentle traction along with the scope under direct visualization. Retrived balloon handed over to the patient\u27s family. The patient was kept in the hospital for monitoring. She reported feeling excellent and that all her abdominal pains and discomfort had resolved completely. Her diarrhea had resolved as well. She was started on GI soft diet which she tolerated well. She was discharged with daily PPI and recommendation to follow up with a gastroenterologist in 1 week for the results of stool HP ag testing for confirming eradication of helicobacter pylori

Esophageal Intramural Pseudodiverticulosis (EIP): A Case Report and Review of Literature

Esophageal intramural pseudodiverticulosis (EIP) is a rare, fortunately benign condition involving the development of numerous outpouchings which protrude from the esophageal lumen to the wall. Patients with EIP are commonly asymptomatic but may present with intermittent, slowly progressive dysphagia, associated weight loss, and possibly bleeding in extreme conditions. The pathophysiology remains unclear, however esophageal hypermotility and chronic esophageal irritation compressing submucosal ducts have been hypothesized in the formation of pseudodiverticula in the esophagus. The aim of this case report is to describe a presentation of an infrequently described rare disorder. A 54-year-old female with past medical history significant for HIV/AIDs on highly active antiretroviral therapy (HAART) presented with worsening dysphagia and odynophagia for five days. She reported to similar symptoms six months prior when she last underwent an EGD. She was diagnosed with esophageal candidiasis and treated with a two-week course of fluconazole. Her physical exam, including abdominal exam, was unremarkable. Complete blood count and comprehensive metabolic panel were within normal range in value. She reported to a CD4 value of 82, which was recently performed and not repeated during this hospitalization. During her hospitalization, she continued to report to persistence of symptoms. She underwent an urgent EGD, which revealed multiple sac-like outpouchings in the esophagus and patchy erythema in the gastric antrum consistent with gastritis. Pathology revealed no evidence of any esophagitis

Splenic Laceration Complication during a Screening Colonoscopy

A Screening colonoscopy is a seemingly routine procedure for most gastroenterologists. With appropriate preparation and visualization one can minimize risks such as perforations, bleeding from biopsies and snare polypectomies or even from adverse reactions to sedatives that are used throughout the procedure. What is less common however, are splenic lacerations that occur secondarily to colonoscopy. We present a case of such complication in a female who presents with chronic abdominal pain for a year after colonoscopy. Our patient is a 64 year old female with a pertinent past medical history of HTN, last colonoscopy one year ago and last EGD 7 years prior. She presents with chronic generalized abdominal pain with occasional localization to the RLQ for the past year. Her presentation is remitting and relapsing in nature without full resolution. She denied any recent NSAID use, recent trauma or any concerns for GI bleeding. Surgery was consulted for concerns of cholelithiasis on ultrasound and possible laparoscopic appendectomy. Findings did not completely explain her initial presentation however thus EGD and Colonoscopy were subsequently planned. EGD illustrated chronic gastritis and colonoscopy was without any significant findings. Patient had a positive HIDA scan and subsequently underwent laparoscopic cholecystectomy. During the procedure however, blood was noted in the peritoneum prior to removal. After removal of the gallbladder, she underwent a CT of the abdomen and pelvis that revealed a Grade 1 splenic laceration without any active extravasation. She was discharged from the hospital with appropriate outpatient follow up within 1-3 weeks