INTRODUCTION:
Intestinal perforation is a rare complication of plastic biliary stents which exclusively occurs in the setting of preceding stent migration. We present the first case series to our ...knowledge of four patients with intestinal perforation from non-migrated in-situ plastic biliary stents.
CASE DESCRIPTION/METHODS:
1: A 65-year-old-woman with biliary stent placement for cholangiocarcinoma-related obstruction presented with acute right upper quadrant (RUQ) pain. She had tachycardia, RUQ tenderness, and elevated liver function tests (LFT). CT scan showed duodenal perforation, and on ERCP a stent was seen perforating through the opposite duodenal wall. Prior straight 10Frx12 cm plastic stent was exchanged for a similar stent with a full external pigtail and a ½ internal pigtail. Over the scope clip was used to close the defect. 2: A 69-year-old-man with biliary stent placement for malignancy-related biliary stricture presented with acute RUQ pain. He had tachycardia, RUQ tenderness, and leukocytosis. CT scan showed duodenal perforation from distal tip of biliary stent with proximal aspect still in the common bile duct (CBD) though ERCP showed no obvious defect. Prior straight 10Frx10 cm plastic stent was exchanged for a similar stent with a full external pigtail and a ¾ internal pigtail. 3: A 60-year-old man with metastatic colorectal carcinoma of the liver with hepatic arterial infusion pump associated biliary sclerosis and stent placement presented with acute RUQ pain. He had leukocytosis, RUQ tenderness, and an acute LFT elevation. ERCP showed biliary stent causing duodenal wall ulceration. Prior 10 F × 12 cm plastic stent was replaced with a similar stent with a full external pigtail and ¾ internal pigtail. 4: A 24-year-old man with NASH cirrhosis status post orthotopic liver transplant and stent placement for anastomotic biliary stricture presented with acute LFT elevation. On ERCP, three plastic biliary stents were seen penetrating duodenal wall with proximal tips in place. Prior straight 10Frx12 cm plastic stents were replaced with similar stents with full external pigtail and a ¾ internal pigtail. An over the scope clip was used to close duodenal defect.
DISCUSSION:
Complication by in-situ plastic biliary stents may be decreased with full external pigtail stents. Stent exchange was successful in all cases, except case 4. This may have been due to the benign etiology of obstruction compared to malignant etiologies for others. An over the scope clip may be used successfully to close duodenal defect.
Introduction: Defecation requires relaxation of the external anal sphincter and puborectalis muscles, which are partially controlled by cortical inhibition of the spinal reflex. Dyssynergic ...defecation results from inappropriate contraction or insufficient relaxation of these muscles during evacuation. The pathogenesis remains unclear and may be subconsciously learned. Given that psychiatric comorbidities may contribute to these subconscious behaviors, thereby increasing the risk of dysfunction, we hypothesized that psychiatric disorders may be more prevalent among patients with dyssynergic defecation. Methods: This was a retrospective cohort study of consecutive patients with chronic constipation who underwent high-resolution anorectal manometry (HRAM) at a tertiary care center in 7/2013-9/2017. Patient demographics, clinical history including psychiatric diagnoses and opioid use, and HRAM data were reviewed. Dyssynergia was defined as impaired anal sphincter relaxation (<20% decrease from baseline) during strain maneuver, with or without presence of weak push, defined as decreased rectal contraction pressure (<40 mmHg increase from baseline). Statistical analyses were performed using Chi-squared or students t-test for univariate analyses and logistic regression for multivariate analysis. Results: 303 patients (mean age: 51.1 years, 87% female) were included, with 134 (44%) having a history of psychiatric comorbidities. HRAM findings of dyssynergia were noted in 162 (53.5%) patients, subclassified as 15.8% type I, 70.3% type II, and 13.9% type IV dysfunction. Dyssynergic defecation was associated with a higher prevalence of psychiatric diagnoses (59.7% vs 40.3%, p=0.05). On subgroup analysis, both depression (28.7% vs 16.4%, p=0.03) and anxiety (21.2% vs 10.3%, p=0.04) were more common among patients with dyssynergia. The distribution of subtypes was similar between patients with psychiatric comorbidities and those without (Table 1). On multivariate analysis controlling for potential confounders, psychiatric comorbidities (OR 2.3, p=0.004) and recent narcotics (OR 2.3, p=0.04) were independently associated with dyssynergic defecation. Conclusion: A history of psychiatric comorbidities and recent narcotics use were independently associated with dyssynergic defecation on HRAM in patients with chronic constipation, and should be considered in the etiology of defecation disorders. Future studies should assess the impact of evaluating and treating these potential targets for intervention.
Introduction: Internal hemorrhoids are common and cause many bothersome symptoms. The cause of symptomatic internal hemorrhoids is not well understood, but associations have been made with chronic ...constipation and older age. Altered bowel habits and anorectal symptoms are common after pregnancy, but the association between obstetric history and hemorrhoidal disease has not been fully evaluated. We hypothesized that internal hemorrhoids are more common in women with a history of vaginal delivery due to the disruption in anorectal anatomy and defecatory function. Methods: This was a retrospective cohort study of adult female patients who underwent both colonoscopy and high resolution anorectal manometry (HRAM) at a tertiary center in 2013 - 2017. Patient demographics, medication use, obstetric history, and endoscopic and HRAM findings were reviewed. Reports and retroflexed images of the colonoscopy were examined for the presence of internal hemorrhoids. Anorectal physiologic parameters and signs of defecation disorders were identified on HRAM. Univariate analyses were performed using Fisher exact test and student t-test, and logistic regression was used for multivariate analysis. Results: 306 patients (mean age: 57.7±11.1 years) were included. Subjects with hemorrhoids discovered on colonoscopy were significantly older (61.2±12.4 vs 54.8±16.4, p=0.0008) than those without. Hemorrhoids were more prevalent among patients with prior vaginal delivery (50% vs 36.7%, p=0.09), particularly among those reporting constipation symptoms (58.1% vs 37.8%, p=0.038). There were no significant associations between hemorrhoids and any HRAM parameters, including resting tone, squeeze pressure, rectal contraction pressure, and simulated defecation response. Trends toward higher prevalence of dyssynergia and reported constipation symptoms among patients with hemorrhoids were noted on univariate analyses, although statistical significance was not reached. On multivariate analysis controlling for potential confounders, a history of vaginal delivery (OR 2.2, p=0.04), older age (OR 3.3, p=0.002), and constipation symptoms (OR 2.5, p=0.02) were independently associated with increased hemorrhoids. Conclusion: A history of vaginal delivery, older age, and constipation symptoms were independent risk factors for internal hemorrhoids, while dyssynergic defecation and other HRAM parameters were not associated. The pathogenesis of internal hemorrhoids are likely due to more than disrupted defecation alone.
ABSTRACT
Plastic biliary stents are associated with rare but potentially life-threatening distal stent migration. We present 4 patient cases with distal migration, whereas the proximal aspect ...remained in the bile duct. Time to stent migration ranged from 1 week to 2 months. Stent migration caused contralateral duodenal wall perforation; 2 underwent endoscopic over-the-scope clip placement for defect closure. All required previous stent removal and stent exchange. This case series highlights that proximal stricture and longer stents have higher migration risk, also shown in the literature. We also show that duodenal perforation can successfully be managed endoscopically with an over-the-scope clip.
Background
Hyperleukocytosis, defined as white blood cell (WBC) count above 100 × 109/L, has high early morbidity and mortality from leukostasis‐related complications, namely intracranial hemorrhage ...and pulmonary distress. Initiating chemotherapy without prior leukocytoreduction may lead to tumor lysis syndrome (TLS). Therapeutic leukocytapheresis (TL) is used as one leukocytoreductive intervention; however, its safety and efficacy in pediatric leukemia has not been established. The purpose of this study is to evaluate safety of TL in pediatric patients and assess the efficacy of TL in reducing WBC count in pediatric leukemia.
Methods
Retrospective chart review was conducted on 14 patients with acute lymphoblastic leukemia (ALL) and 5 with acute myeloid leukemia (AML) who underwent TL during the period 2000‐2014 at a single institution.
Results
Mean WBC count of 19 patients who received TL was 483.2 × 109/L (547.1 in ALL, 304.3 in AML); a portion of patients presented with central nervous system symptoms (15%), respiratory symptoms (10%), or both (10%). TL reduced WBC count (mean 50.7% reduction after a single TL procedure; additional 17.1% reduction after a second TL procedure in 6 patients). Short‐term survival immediately following TL was 100% without any major procedural complication. Mean survival time in patients with AML was 1.5 years and with ALL was 6.5 years.
Conclusions
TL significantly reduces WBC number in pediatric leukemia patients as young as 22 days old. In our retrospective study, TL was not associated with any significant complications and suggests that TL is a safe initial procedure in pediatric leukemia.
Atrioesophageal fistula (AEF) is a rare complication of atrial fibrillation ablation. We present a man with sepsis and frank hematemesis 3 weeks after atrial fibrillation ablation. Thoracic computed ...tomography showed no definitive evidence of AEF. He underwent esophagogastroduodenoscopy and subsequently developed an embolic stroke. In the operating room, he was found to have AEF. This case highlights the importance of maintaining a high index of suspicion for AEF because of its nonspecific presentation and difficulty in diagnosing with imaging or endoscopy. Once AEF is suspected, esophagogastroduodenoscopy should be avoided because of the risk of precipitating embolic events.
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