Secondary Choledocholithiasis in Obstructive Jaundice Patient due to Choledochoduodenal-fistula Stricture.

Choledochoduodenal fistula (CDF) is a rare condition marked by an abnormal connection between the biliary duct and duodenum. The common etiology of secondary CDF are cholecystolithiasis, tumor, and duodenal ulcer. CDF may also caused by prior inflammatory condition or as a complication of radiation therapy. Management for this case is based on the patient condition. Herein we aimed to present a case of secondary choledocholithiasis due to stricture in the CDF which presented with cholangitis treated by self-expanding metal stent (SEMS) for biliary drainage. Patient admitted with jaundice, fever, right upper quadrant pain, and history of cholecystectomy. Diagnosis of CDF was determined by endoscopic retrograde cholangiopancreatography (ERCP) and followed by putting biliary stent for urgent biliary drainage. The follow up result after stent removal was excellent.

Gastroptosis due to Gastric Outlet Obstruction Secondary to Duodenal Tumor: Glenard's Disease Revisited.

Currently, gastroptosis is rarely reported, and the actual prevalence is unknown. Similarly, the possible predisposing factor and cause remain unclear. A 69-year-old had melena for 1 week, and other symptoms were left upper abdominal pain, nausea, and vomiting especially postprandially that was persistent for several months with no response to medication. The nasogastric tube produced yellowish discharge and dark-colored undigested material. The CT scan showed obstruction of the gastroduodenal junction and gastroptosis. Endoscopy revealed a gastric lumen that was extended inferiorly and an occluded pyloric ring by a bleeding mass protruding from the duodenum. We report the first case of gastroptosis caused by gastric outlet obstruction secondary to duodenal tumor.

Pancreas Divisum as a Rare Etiology of Recurrent Pancreatitis: A Rare Case Ever Documented and Reported In Indonesia.

Pancreas divisum is an abnormal condition of pancreas duct that occurs from organogenesis. This abnormal condition defined as a failure in fusion between dorsal and ventral part of the pancreas. The incidence reported 4%-14% in general population. Majority patient with pancreas divisum will not present with any sign or symptom, but in some cases may present with signs of pancreatitis. We illustrate a case of 39 years old male with pancreas divisum presenting as acute recurrent pancreatitis. Diagnosis of pancreas divisum was determined through magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP). Patient treated by sphincterotomy and dilation using Soehendra's dilator catheter. This is the first pancreas divisum case successfully treated and reported in Indonesia.

Hemospray® during Emergency Endoscopy: Indonesia's First Experience from 37 Patients.

Gastrointestinal bleeding (GIB) is one of the main indications for performing endoscopy; this condition can be life threatening. In some cases, emergency endoscopy (EE) is necessary to identify the source and stop the bleeding. Recently, hemostatic powder was introduced, one of which was Hemospray® (Cook Medical, Winston-Salem, NC, USA), which showed promising results for rapid hemostasis in primary treatment and salvage when conventional methods fails. Samples were taken retrospectively for a duration of 3 years since Hemospray was first introduced in Indonesia, from January 2016 to January 2019. The total number of EEs that used Hemospray were 37 procedures for 37 patients; 21 (56.8%) were males and 16 (43.2%) were females, while the average age was 67.8 years. Hemospray was used for upper GIB in 30 cases (81.1%) and for lower GIB in 7 (18.9%). Hemospray was used as monotherapy for 24 patients (64.9%) and as secondary modality for 13 (35.1%). The primary treatment was argon plasma coagulation in 8 cases (21.6%), adrenaline in 4 (10.8%), and Histoacryl® in 1 (2.7%). The mortality rate was 37.8% (n = 14); most deaths occurred within 30 days after the EE was performed, and none of the deaths was related to endoscopy or GIB. Hemospray was able to achieve hemostasis in all cases. Furthermore, there was no event of rebleeding. When conventional modalities alone were inadequate, the combination with Hemospray appeared to be able to control the bleeding. One of the main advantages of Hemospray is the ease in reaching difficult areas, and it require less skill compared to conventional modalities.

Low-Stage Gastric MALT Lymphoma Causing Life-Threatening Upper Gastrointestinal Bleeding.

Gastric mucosa-associated lymphoid tissue (MALT) lymphoma is an uncommon tumor of the stomach that only comprises around 1-6% of all tumors of the stomach. Non-Hodgkin lymphoma more commonly affects the lymph nodes and may spread to the spleen and bone marrow, whereas extranodal non-Hodgkin lymphoma is less common. Primary gastric lymphoma is further divided based on histologic features; one of the types is MALT lymphoma, which is strongly associated with Helicobacter pylori infection. The first sign of the disease is usually mimicking gastritis. However, in the case reported here, the first sign of gastric MALT lymphoma was massive gastrointestinal (GI) bleeding with hemodynamic instability in a 75-year-old male. The patient came to the emergency department and was immediately resuscitated, intubated, and admitted to the intensive care unit. Urgent endoscopy (<6 h) was done to identify the source of bleeding, which were oozing ulcerated polypoid masses; endoscopic hemostasis was done, which successfully stopped the bleeding. However, the next day, rebleeding occurred and a second endoscopic hemostasis was performed. The bleeding stopped and the patient showed gradual improvement. The biopsy result of a gastric MALT lymphoma of grade IE1 with H. pylori infection warranted a treatment regimen for Helicobacter eradication. The patient recovered, with follow-up endoscopy at 3 months, at 6 months, and yearly thereafter with no sign of recurrence. This case shows that gastric MALT lymphoma, even at a low stage (1E1), can cause life-threatening upper GI bleeding that requires aggressive resuscitation and urgent endoscopy.

Clindamycin-Induced Esophageal Injury: Is It an Underdiagnosed Entity?

There are increased reports of pill-induced esophagitis in the past 2 decades, with almost 100 different substances identified as the cause for more than 700 cases, and the overall incidence is estimated to be 0.004% per year. Antibiotics are one of the major contributors for these cases, especially tetracycline and doxycycline; other major contributors are bisphosphonates, nonsteroidal anti-inflammatory drugs, and iron pills. Clindamycin is commonly prescribed by physicians, yet side effect in the form of esophagitis is uncommon and mostly documented in case report. It is possible that these cases are mostly unnoticed due to initial consideration of common and more serious problems. Thus, patients may be assumed to be having a severe episode of acid reflux, and it is not routinely reported or recognized. In this case series, we presented 8 patients with clindamycin-induced esophagitis. The initial presentation of all patients was odynophagia, which appeared within the first day of taking the antibiotic. All patients were subjected to endoscopic examination and ulcer was found in all cases, in the form of localized solitary or multiple ulcers with sharply defined borders. Patients were treated with proton pump inhibitor and sucralfate, and the symptoms subside within 1 week. Patient education regarding the proper way of ingesting drug seems to be the key factor in the prevention of pill-induced esophagitis. The prevention of esophagitis is even more important with antibiotics as adverse effect would decrease the patient compliance in completing the regimen and would ultimately increase antibiotic resistance.

Endoscopic ultrasound in the diagnosis of occult pancreatic head cancer.

Two consecutive female patients presented with progressive jaundice, epigastric pain and weight loss. Cross-sectional imaging with computer tomography and magnetic resonance imaging did not show any mass lesions whereas magnetic resonance cholangiopancreatography showed common bile duct strictures. Both patients were then referred for endosonographic evaluation. Endoscopic ultrasound showed occult pancreatic head masses in both cases and endoscopic ultrasound guided fine needle aspiration confirmed the diagnosis of pancreatic cancer. Both patients then successfully underwent endoscopic palliation with endoscopic ultrasound guided celiac plexus neurolysis and insertion of self expandable metallic biliary stents. This case is reported to describe the diagnostic and therapeutic impact of endoscopic ultrasound in the management of occult pancreatic head cancer. Endoscopic ultrasound is useful in the management of pancreatic cancer. It can detect occult pancreatic lesions, provide tissue diagnosis and facilitate pain palliation.