INTRODUCTION:
Pancreaticobiliary obstruction is an uncommon complication of total gastrectomy with Roux-en-Y reconstruction. We present a case of a patient with a closed loop obstruction due to a ...hematoma at the location of jejunojejunal anastomosis. The patient underwent EGD with clot evacuation resulting in decompression of the pancreaticobiliary limb.
CASE DESCRIPTION/METHODS:
A 57-year-old male, with hypertension, who had recently immigrated from China presented for evaluation of persistent heartburn. He underwent an upper endoscopy, which showed erythematous gastric mucosa and pathology was positive for superficial invasive adenocarcinoma. He was referred to surgery and underwent laparoscopic esophagogastroduodenoscopy, robotic assisted total gastrectomy and Roux-en-Y reconstruction with jejunostomy tube placement. On postoperative day one, there was bright red blood on aspiration from his nasogastric tube and J-tube. Laboratory tests were notable for downtrending hemoglobin and he required 2 units of packed cells. Due to concern for active bleeding, the patient underwent an upper endoscopy in the operating room, which demonstrated no active bleeding and presence of a blood clot at the JJ anastomosis. Epinephrine was injected at the site of the clot. Post procedure, he had increasing total bilirubin which peaked at 5.9. A computed tomography was done on postoperative day 3, demonstrating marked dilation of the pancreaticobiliary limb, which was suspicious for a clot within the small bowel at the level of the JJ anastomosis, concerning for a closed loop obstruction. He then underwent a repeat endoscopy using a duodenoscope. A 9 cm clot was visualized at the JJ anastomosis causing pancreaticobiliary obstruction. The clot was removed with cold soft snare, grasping forceps and roth net with resultant free flow of bile at the site of JJ anastomosis. Total bilirubin subsequently downtrended and returned to normal. The patient's recovery was uneventful, and he was discharge 16 days after clot evacuation.
DISCUSSION:
The most common early complications of total gastrectomy with Roux-en-Y reconstruction include SBO and anastomotic leak. Our case highlights a rare complication of pancreaticobiliary limb obstruction due to hematoma at the JJ anastomosis. Early EGD allowed for clot evacuation and limb decompression without need for re-operation.
INTRODUCTION:
Immune checkpoint inhibitors are a group of novel treatment agents that are used for the treatment of multiple metastatic malignancies. Among these are programmed cell death 1 receptor ...(PD-1) antibodies that promote T cell proliferation, activating the immune response to tumor cells as well as non-tumor cells causing immune-related adverse events (irAEs). Diarrhea and colitis are common irAEs. Upper gastrointestinal involvement is rare with esophagitis limited to only case reports.
CASE DESCRIPTION/METHODS:
A 74-year-old female with metastatic renal cell carcinoma developed throat pain and dysphagia after 10 doses of Nivolumab. Proton pump inhibitor (PPI) and viscous lidocaine improved her symptoms. After 20 doses of therapy she developed odynophagia and dysphagia to both liquids and solids. She underwent an esophagogastroduodenoscopy which revealed esophagitis of 13 cm in length, manifest as circumferential erythema and exudate. Biopsy confirmed active esophagitis with dyskeratotic keratinocytes and lymphoplasmacytic infiltrate. Immunohistochemistry demonstrated markedly increased polyclonal plasma cells. This was consistent with nivolumab-induced esophagitis. Nivolumab was discontinued and she was started on methylprednisolone, with rapid improvement in symptoms and subsequent transition to prednisone. She was treated with a prolonged 3-month taper, but her dysphagia to solids recurred 2 months after completing the steroids. Repeat endoscopic biopsies were consistent with reflux esophagitis. She was treated with topical steroids for suspected residual Nivolumab-induced esophagitis as well as PPI with improvement in symptoms. Ten months later, the patient developed dyspepsia and early satiety. Repeat endoscopy showed discolored, linearly eroded, friable, sloughing mucosa. Biopsies taken revealed active and chronic esophagitis with lymphocytic infiltrate again consistent with Nivolumab-induced esophagitis. The patient symptomatically improved with sucralfate and PPI, and treatment was not further escalated.
DISCUSSION:
This is a rare case of Nivolumab-induced esophagitis demonstrating initial improvement with prolonged steroid taper followed by recurrent symptoms and persistent endoscopic disease treated with acid suppression, sucralfate and topical steroids. For refractory symptoms of esophagitis, immunosuppressants such as Infliximab could be considered. It is important to recognize the diversity and severity of immune-related adverse events to avoid incomplete treatment or a delay in therapy.
INTRODUCTION:
AIDS-related Kaposi sarcoma (KS) is a vascular tumor associated with infection by the human herpesvirus-8 (HHV-8) that most commonly affects mucocutaneous sites. In its disseminated ...form, it can also involve lymph nodes and visceral organs, in particular the respiratory and gastrointestinal tract. Visceral involvement as the initial manifestation of KS is extremely rare and carries a worse prognosis. We present a case of a 54-year-old Male with disseminated KS with rectal involvement presenting with cough and chills.
CASE DESCRIPTION/METHODS:
54-year-old Male with a past medical history significant for HIV, not adherent with HAART therapy, who presented to the Emergency Department (ED) with a chief complaint of cough and subjective chills of three days duration. He later endorsed recent sick contacts, bloody diarrhea, and a 40 lb weight loss over the last year. In the ED, he was hypotensive and tachycardic and found to have a CD4 13 with a viral load of 3 million copies/ml. A CT Chest showed evidence of bilateral pleural effusions for which he was started on broad spectrum antibiotics. He underwent bronchoscopy with BAL which showed small nodules suspicious for KS versus Lymphoma. His hospital course was complicated by microcytic anemia (Hb 6.1 on admission) with a positive fecal occult test requiring multiple blood transfusions. Gastroenterology was consulted and the patient underwent colonoscopy which showed evidence of a large, non obstructing, fungating mass in the distal rectum. The mass had a purple hue, was noncircumferential, and was confluent with multiple scattered oozing purple sessile nodules. Biopsies were taken with cold forceps for histology. The rectal biopsy was positive for Human Herpes Virus 8 (HHV-8) and he was diagnosed with disseminated KS. He was subsequently transferred to the National Institutes of Health Clinical Center in Maryland after failed initial treatment for further management and care.
DISCUSSION:
Visceral involvement as the initial presentation of KS is rare and carries a worse prognosis. While gastrointestinal KS lesions are usually asymptomatic, they may also cause a wide array of symptoms including nausea and vomiting, weight loss, upper or lower gastrointestinal bleeding, and abdominal pain. Because visceral involvement is rare as the initial presentation, the possibility of disseminated KS in an immunocompromised patient is often over looked and thus, a high index of suspicion is required.
INTRODUCTION:
Acute variceal bleeding is a severe complication of portal hypertension. Endoscopic banding successfully controls the vast majority of acute variceal bleeding. Refractory variceal ...bleeding refers to a small percentage of acute variceal bleeding not controlled by endoscopic therapy, requiring more aggressive modalities such as a Sengstaken–Blakemore tube. We present a case series of two patients with hematemesis secondary to varices, requiring the use of Self-expandable metal stents (SEMS) with successful hemostasis.
CASE DESCRIPTION/METHODS:
Patient 1: A 38-year-old male with decompensated cirrhosis in the setting of alcohol use complicated by esophageal varices presented with hematemesis. On presentation, he was hypotensive and tachycardic with several large bouts of hematemesis prompting endotracheal intubation for airway protection. He required a massive transfusion protocol and was started on vasopressor support. Initial upper endoscopy showed five columns of large varices (>5 mm) in the middle third and lower third of the esophagus. One varix was actively spurting at about 38 cm from the incisor, for which four bands were successfully placed with resolution of the active bleeding. The patient had a repeat episode of massive hematemesis the following day requiring upper endoscopy during which active bleeding was appreciated but a source could not be accurately identified. Due to lack of visualization, banding could not be repeated and a fully covered 23 mm × 105 mm esophageal stent was placed starting at 30 cm from the incisor to the GE junction with excellent hemostasis. The patient had no further episodes of hematemesis and was transferred for liver transplant evaluation. Patient 2: A 30-year-old male with incompletely treated hepatitis B complicated by hepatocellular carcinoma invading the portal vein and extending to the Superior Mesenteric Vein presented with hematemesis. He was intubated and required upper endoscopies on two consecutive days for management of active bleeding from esophageal varices with banding. He was considered not to be a candidate for TIPS. On day 3, he had another episode of hematemesis causing hypotension. An upper endoscopy was performed and a fully covered esophageal stent was placed to tamponade the varices. He did not have any more episodes of bleeding in the remaining hospitalization.
DISCUSSION:
SEMS should be considered as an option for management of refractory variceal bleeding.
INTRODUCTION:
Amyloidosis is a heterogenous disease, characterized by the extracellular deposition of an abnormal fibrillar protein, which disrupts tissue structure and function. Gastrointestinal ...involvement in amyloidosis is a rare entity that can result from mucosal and neuromuscular infiltration, or extrinsic autonomic neuropathy. Diagnosis is difficult as significant variation can exist within an individual type of amyloid and visceral involvement is rarely on a clinicians differential diagnosis. We present a case of gastrointestinal amyloidosis in a 62 year old Male who presented with nausea and vomiting.
CASE DESCRIPTION/METHODS:
62 year old Male with a past medical history significant for tobacco use presented to the Emergency Department (ED) with a chief complaint of nausea and non bloody-non bilious emesis of three weeks duration. He reported early satiety, abdominal bloating, and unintentional 40 pound weight loss over one year. Several days prior to his presentation, he developed bilateral lower extremity edema. He denied any nausea, hematemesis, dysphagia, abdominal pain, melena or hematochezia and never had a previous upper or lower endoscopy. On presentation to the ED, his vitals were stable. He was ill appearing with temporal wasting and his abdomen was soft, nontender, without hepatosplenomegaly. Laboratory data was notable for a Hemoglobin 9.8 (MCV 78), Albumin 1.7, and a positive fecal occult test. Gastroenterology was consulted and the patient underwent an upper endoscopy given red-flag symptoms. His endoscopy revealed an edematous GE junction, severe diffuse gastric erythema with erosions, congested and friable gastric body folds, deformed duodenal bulb and edematous second portion of duodenum suspicious for extrinsic compression. Endoscopic biopsies were obtained using cold forceps. Small bowel biopsies detected amyloid deposits supporting a diagnosis of AL (lambda)- type amyloid deposition. He was referred to Hematology/Oncology and was subsequently started on standard triple therapy including lenaolidmide, bortezemib, and prednisone.
DISCUSSION:
Biopsy proven amyloidosis of the gastrointestinal tract is rare. Because presentation is insidious, with multiple vague symptoms, the possibility of systemic amyloidosis is often overlooked, resulting in substantial delays in diagnosis. A high index of suspicion is therefore required. Staining for amyloidosis should be considered in patients undergoing gastrointestinal biopsy who have unexplained chronic gastrointestinal symptoms.
Abstract only Background: There is conflicting evidence concerning the obesity paradox in stroke patients. We sought to examine the relationship between gender, BMI, and prevalence of comorbidities ...in patients with non-hemorrhagic stroke. Materials and Methods: Retrospective chart review was performed in 996 consecutive patients treated for non-hemorrhagic stroke at a single academic medical center. Patients were divided according to gender and specific BMI groups according to the National Institute of Health. This study was approved by the institutional IRB. Results: Patients with BMI from 0-18.5 and 18.5-24.9 were more likely to be female (63.2% and 58.4% p<.05). Whereas patients with BMI over 25-30 and 30-35 were more likely to be male (60.82% and 59.2% p<.05). Morbidly obese patients (BMI>35) were equally likely to be men or women. In men higher BMI correlated with presentation at younger age. Diabetes was most prevalent in patients with BMI over 35 (40% males, 44% females, p<.05). In females, HTN was associated with BMI 30-34.5 and 35+ (80.5% and 73.3%, P<.05). Males showed a similar though non-significant trend. The prevalence of end stage renal disease, systemic atherosclerosis, and PVD was not significantly correlated with BMI in either gender. Conclusion: Gender and BMI significantly affect associated comorbidities in patients with non-hemorrhagic stroke, possibly suggestive of unique gender specific disease mechanisms. Additional studies investigating the effect of gender and BMI on diagnostic evaluation and treatment of patients with non-hemorrhagic stroke are warranted.
PDF
