Palliative Stenting for Gastric Outlet Obstruction Secondary to Pancreatic Adenocarcinoma.

Pancreatic cancer is one of the most fatal malignancies due to its advanced stages at the time of presentation. Often, it is only diagnosed when patients present with late-stage complications, such as gastric outlet obstruction (GOO). Many patients experience a poor quality of life due to the side effects of GOO, such as persistent nausea, vomiting, and an inability to tolerate an oral diet, and as such, patients deteriorate quickly after their diagnosis. Because pancreatic cancer is diagnosed at advanced stages, many patients are not surgical candidates, and thus treatment is tailored for palliative measures. With GOO specifically, gastrojejunostomy has been the mainstay of palliative management; however, endoscopic stent placement is a new, innovative, and minimally invasive alternative option. Herein, we present a case of GOO as a complication of pancreatic adenocarcinoma, treated with palliative endoscopic stent placement. Further research is warranted to identify patients who would most benefit from this modality of palliation in the treatment of advanced pancreatic cancer.

Incidence of Pneumoperitoneum After Gastrostomy Tube Removal.

We present the case of an 88-year-old man with a previous medical history of severe colitis and colonic strictures who presented with hematemesis. The patient was found to have a lower esophageal ulcer without any signs of perforation. Esophagogastroduodenoscopy (EGD) revealed a scar in the greater curvature of the stomach from a previously removed gastrostomy tube two months prior. On CT imaging, an incidental finding of pneumoperitoneum was also found alongside stomach perforation near the healing scar. Due to the lack of evidence of any other colonic perforation, the patient was believed to have developed this pneumoperitoneum status post-gastrectomy tube removal two months prior to presentation. Pneumoperitoneum has a wide range of presenting symptoms that vary in severity and nature, and our patient failed to present with any physical or laboratory signs of infection. Over the course of the next four months, the patient was monitored with serial CT scans, during which the pneumoperitoneum resolved. In this report, we present a case of a patient who was found to develop pneumoperitoneum post-gastric tube removal and its complete resolution without surgical or procedural intervention.

Esophageal Stab Wounds Repaired Endoscopically: A Case Report and Comprehensive Literature Review.

Esophageal injuries are typically iatrogenic after endoscopic/surgical procedures, but they are rarely caused by penetrative or blunt trauma. We present a case of patient who suffered multiple stab wounds to the neck and underwent surgical repair for hemorrhagic shock but was ultimately diagnosed and treated successfully via endoscopy for a thoracic esophageal injury. Early detection is imperative and usually diagnosed via contrast studies but less commonly via direct visualization endoscopically. Moreover, endoscopic treatment is also less commonly utilized, even if diagnosed from that modality. Cervical injuries also confer a lower mortality than thoracic injuries.

Isolated IgG4 Autoimmune Cholangitis in the Absence of Pancreatitis.

The IgG4-related disease is an uncommon immune-mediated condition affecting multiple organ systems concomitantly; however, it is very rare for a patient to have isolated IgG4 autoimmune cholangitis or IgG4-related disease confined to the hepatobiliary system. The majority of cases are associated with pancreatitis and are incidentally discovered in the workup of acute or chronic pancreatitis. When it affects the hepatobiliary system, it develops as inflammatory fibrosclerosing cholangitis, which can mimic other hepatobiliary diseases such as primary sclerosing cholangitis. Herein, we present a case of type 1 IgG4 autoimmune cholangitis in the absence of pancreatitis. Our case is particularly unique because type 1 is the most common type associated with autoimmune pancreatitis; however, our patient had type 1 without any evidence of pancreatic involvement. Additionally, like most cases of isolated IgG4 autoimmune cholangitis, our patient was refractory to standard therapy. This case highlights the clinical significance, rarity and severity of isolated IgG4 autoimmune cholangitis.

Perirectal Extragastrointestinal Stromal Tumor: An Unusual Presentation.

Gastrointestinal stromal tumors (GISTs), even though rare, remain the most common mesenchymal tumors of the gastrointestinal (GI) tract. When GISTs occur outside of the GI tract, they are termed extragastrointestinal stromal tumors (EGISTs). Most GISTs arise from the stomach (50-70%) and small intestine (20-30%). A smaller percentage of these tumors also occurs in the large intestine (5%) and esophagus (2-5%). EGISTs have histopathological and molecular characteristics that are similar to GISTs. However, the precise incidence and tumor behavior of EGISTs are not fully understood. EGISTs have no specific symptoms or radiologic features, and in most cases, the presenting complaint is abdominal pain or discomfort. Yet, they tend to be more aggressive and have a worse prognosis than GISTs. Morphologic diagnosis based on microscopic examination of histological sections is the standard diagnostic procedure for GIST/EGIST. In this patient-centered study, we present a case of EGIST that originated in the anterior perirectal space, an extremely rare location; we also describe the endoscopic approach that was used to biopsy the tumor.

Hybrid Argon Plasma Coagulation for Treatment of Gastric Intestinal Metaplasia.

Hybrid argon plasma coagulation (HybridAPC® [HAPC]) is an evolution of the standard argon plasma coagulation (APC) technology, where the application of APC is preceded by high-pressure needleless submucosal injection. APC is indicated for the ablation of benign and dysplastic mucosal lesions, such as vascular malformations or Barrett's mucosa. HAPC offers safety and efficacy advantages over standard APC because the submucosal injection acts as a heat sink that disperses energy. This ensures that the underlying muscularis propria remains unaffected, and only the mucosal layer is coagulated in its entirety. An 81-year-old Hispanic male was found to have a 1.2-cm mucosal nodule along the incisura of the stomach. Pathology of the biopsy specimen revealed high-grade dysplasia, and he subsequently underwent endoscopic ultrasound examination, which confirmed the presence of an isolated gastric nodule with no deep invasion of the muscularis propria, consistent with a uT1N0Mx endosonographic staging. He then underwent endoscopic submucosal dissection of the lesion. Pathology of the excised specimen confirmed the presence of multifocal high-grade dysplasia, arising in the background of extensive intestinal metaplasia. The deep margin was clear; however, the lateral resection margins showed focal involvement of intestinal metaplasia with low-grade dysplasia. Surveillance endoscopy confirmed the persistence of diffuse intestinal metaplasia. He was then treated with widespread HAPC due to the presence of underlying diffuse intestinal metaplasia in the stomach. HAPC is an effective and efficient treatment modality for mucosal lesions. In one series of 50 patients, 96% achieved complete macroscopic remission of Barrett's mucosa after a median of 3.5 APC sessions, and 85% achieved complete histological remission. HAPC is a promising therapeutic modality as a thermal injury is targeted, and the depth of injury is contained. This provides immediate procedural efficacy and safety benefits, and reduces subsequent complications when compared with standard APC. We anticipate that the applications of HAPC will continue to grow, as this modality is adopted into common procedural parlance. This case appears to be the first to describe the use of HAPC for definitive treatment of diffuse intestinal metaplasia.

Upper Gastrointestinal Crohn's Disease: Literature Review and Case Presentation.

Upper gastrointestinal tract predominant Crohn's Disease (CD) remains an elusive clinical entity, manifesting limited or vague symptomatology, eluding clinical suspicion, and delaying subsequent diagnostic evaluation. As a result, it has not been widely described and there is a lack of clear recommendations for diagnosis or management. Standard IBD evaluation including serologic testing, imaging, and endoscopy may initially not be fruitful. Furthermore, endoscopic evaluation may be grossly normal in patients without long standing-disease. We describe an 18-year-old male who presented with only unexplained, persistent iron-deficiency anemia. Extensive outpatient testing including multiple endoscopic evaluations with standard biopsies was unfruitful. Ultimately, a positive fecal calprotectin prompted enteroscopy with endoscopic mucosal resection (EMR) in an effort to obtain a larger, deeper tissue specimen. Grossly cobblestoned mucosa along with histopathology revealing focal crypt abscesses, chronic inflammation in the lamina propria, and superficial foveolar epithelial regenerative changes were consistent with CD. This patient's case illustrates the need for a high degree of suspicion for CD in patients with unexplained or persistent iron deficiency anemias. Persistent investigation yielded an elevation in fecal calprotectin suggesting underlying gastrointestinal inflammation and prompted advanced endoscopic evaluation with EMR. Waxing and waning tissue findings are characteristic of CD and pose a unique challenge in patients with upper gastrointestinal predominant pathology. As such, diligent workup including laboratory evaluation, imaging, and serial endoscopy is critical to establish pathology and dictate subsequent management in IBD, especially upper gastrointestinal tract predominant CD.