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Video 1This video details our case as well as our method for successfully eradicating varices immediately prior to esophageal endoscopic submucosal dissection to minimize risks of variceal hemorrhage.
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Video 1Submucosal nodule in the cecum. After submucosal injection, a circumferential incision of the mucosa surrounding the lesion is performed with DualKnife (Olympus America, Center Valley, Pa, USA). The fore-balloon of the double-balloon endoluminal interventional platform (DBEIP) is deployed and the edges of the circumferential incision are attached with 2 endoscopic clips to the long suture-loop mounted on the fore-balloon of the DBEIP. The fore-balloon is retracted in anal direction, pulling the lesion into the cecum. Careful endoscopic submucosal dissection is performed with DualKnife and HookKnife (Olympus America). Dissection is markedly facilitated by traction and continued until the entire appendix is pulled into the cecum. The tip of the appendix is separated from surrounding tissues, resulting in a full-thickness cecal wall defect. The suture-loop holding the resected appendix is cut with LoopCutter (Olympus America). The resected appendix is removed through DBEIP and the Overstitch endoscopic suturing device (Apollo Endosurgery, Austin, Tex, USA) is advanced into the cecum. The full-thickness defect in the cecal wall is completely closed with 2 continuous sutures. The final view demonstrates the entire resected appendix.
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Sump syndrome - a collection of digested food, debris, stones, bile, and bacteria in a poorly drained, bile duct reservoir - occurs most commonly after a side-to-side choledochoduodenostomy. As choledochoduodenostomies are now less common, sump syndrome is more often characterized as a complication of Roux-en-Y hepaticojejunostomies; however, most cases occur at the hepaticojejunostomy anastomosis. We report a rare case of sump syndrome in the intra-pancreatic remnant common bile duct in a patient with primary sclerosing cholangitis following living donor liver transplant via Roux-en-Y hepaticojejunostomy. Our patient had a history of end-stage liver disease secondary to primary sclerosing cholangitis but presented with recurrent bacteremia and symptoms of acute cholangitis following her transplant. While this complication has not been reported in this population, we know that those with primary sclerosing cholangitis and those undergoing liver transplantation are at very high risk for biliary complications and strictures. Liver transplant is currently our only treatment for primary sclerosing cholangitis, and more than any other group, they are referred for living donor liver transplantation, preferably via Roux-en-Y hepaticojejunostomy. Thus, our patient's clinical scenario is not uncommon and demonstrates a source of serious infection of which providers must be aware.
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Pancreatic pseudocysts are often drained endoscopically after 4-6 weeks of maturation. Allowing for developed encapsulation ensures that the cyst walls are strong enough to sustain drainage. However, in 3%-5% of these cases, pseudocysts will rupture spontaneously and put patients at risk of peritonitis. We present the first documented case of pancreatic pseudocyst rupture after upper endoscopy. Exploratory laparotomy confirmed the absence of viscus perforation and highlighted the danger of any procedure that increases intra-abdominal pressure in a patient with a pancreatic pseudocyst. Awareness of this complication should impact our decision when considering endoscopy in patients with pancreatic pseudocysts.
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In the evaluation of patients with inflammatory bowel disease, assessment of extraintestinal manifestations of disease is integral to clinical management. The patient described in this case is a 24-year-old woman with a history of inflammatory colonic Crohn's disease (CD) who presented to the hospital with one week of vaginal pain and swelling. Initial assessment focused on infectious etiologies, though final diagnosis of vulvar CD was made on biopsy. Clinical course and treatment of vulvar CD are poorly defined in existing literature. This case highlights the multidisciplinary management of inflammatory bowel disease patients and successful treatment of a rare extraintestinal manifestation with anti-interleukin 12/23 therapy.
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Autoimmune enteropathy is an uncommon cause of chronic diarrhea rarely seen in adults. The disease is secondary to an autoimmune process in the gut that leads to villous blunting and subsequent watery diarrhea, abdominal pain, and severe weight loss. The disease has only been described in 37 adults prior to our case, and variable treatment success has been documented with steroids, immunomodulators, and TNF-α inhibitors. This case is the first to show success in treating autoimmune enteropathy with vedolizumab and provides physicians with an additional therapeutic option when limited by a patient's comorbidities and side effects of other drugs.
