The Diagnostic Yield of Endoscopic Ultrasound in Asymptomatic Patients with Unexplained Dilated Common Bile Duct, or Double Duct Sign with Normal Transaminase a Retrospective Study from a Single Urban-based University Endoscopy Center.

Background: Common bile duct dilatation alone or double duct sign (both CBD and dilated pancreatic duct dilatation) and abnormal liver enzymes are highly predictive of biliary disease. This can be identified on ultrasound (US), CT scan, and/or magnetic resonance cholangiopancreatography (MRCP). Unexplained dilatation on imaging might warrant endoscopic ultrasound (EUS) to identify any occult causes. Supporting literature about the importance of using EUS in these conditions is evolving with no clear evidence-based approach to evaluate asymptomatic dilated ducts.We aim to investigate the diagnostic yield of EUS in unexplained CBD dilatation or double duct sign with normal liver enzymes. Method: A retrospective data analysis was conducted from January 2015 to October 2021 on asymptomatic patients with a dilatated CBD of 7 mm or more and 9 mm if the patient had a cholecystectomy history or double duct sign with normal liver enzymes. Result: 32 EUS procedures were indicated for unexplained dilated CBD or double duct sign on imaging with normal liver enzymes. 23 had CBD dilatation alone (72 %), and 9 had a double duct sign (28 %). 20 of the included patients were females (63 %), and 12 were males (37 %), with a mean age of 63.8 ± 17 and 68.2 ± 14 years old, respectively (p = 0.424). The diagnosis after EUS in CBD dilatation alone showed a yield of 56 % as follow; no pathology in 10 (44 %), sludge in 9 patients (39 %), CBD stone in 3 (13 %), malignant stricture in 1 (4 %) (Fig. 1). On the other hand, EUS in those with double duct signs showed a diagnostic yield of 55 %; no pathology in 4 (45 %), pancreatic head adenocarcinoma in 3 patients (33 %), Biliary stone in one patient, and malignant CBD stricture in one patient (11 % each) (Fig. 2). Conclusion: Unexplained CBD dilatation or Double duct sign on imagining in patients with normal liver enzymes should warrant further investigation with EUS to avoid missing serious pathological conditions such as stones, sludge, stricture, or a mass.

Sinistral Portal Hypertension Due to a Pancreatic Pseudocyst: A Rare Cause of Upper Gastrointestinal Bleeding.

Sinistral portal hypertension (SPH), also known as segmental portal hypertension, is a complication of pancreatic disorders and an extremely rare cause of upper gastrointestinal (GI) bleeding. SPH is observed in patients without cirrhosis and arises from splenic vein thrombosis. Unmitigated backflow of blood may cause gastric venous congestion and ultimately GI hemorrhage. Herein, we report a rare case of massive hematemesis due to SPH in a male patient with a history of chronic pancreatitis and pancreatic pseudocyst. Our patient was successfully treated with endoscopic necrosectomy followed by open splenectomy, distal pancreatectomy, and partial gastric resection.

An Unpleasant Souvenir: Whipworm as an Incidental Finding During a Screening Colonoscopy.

Trichuriasis is a neglected tropical disease caused by Trichuris trichiura that spreads through the ingestion of embryonated eggs in contaminated soil, water, or food. In nonendemic areas, T trichiura infestation is very rare and sporadic and is often diagnosed in immigrants from endemic countries such as the Philippines. Whipworms feed on human blood and also erode the colonic mucosa, thereby evoking an inflammatory response. In milder forms, trichuriasis can be asymptomatic and often an incidental diagnosis on screening colonoscopy. Heavily infested patients usually present with abdominal pain, nausea, vomiting, tenesmus, chronic diarrhea, iron deficiency anemia, or stunted growth. T trichiura worms can be removed with biopsy forceps during a colonoscopy; however, most patients require a course of albendazole, mebendazole, or ivermectin. We describe a unique case of T trichiura as an incidental finding during a screening colonoscopy. The whipworms were retrieved using biopsy forceps and the patient was treated with albendazole. At the time of the colonoscopy, the patient did not exhibit any specific symptoms related to the worm infestation.

Acute Mesentero-Axial Gastric Volvulus in the Setting of a Paraesophageal Hernia: A Rare Case Report.

Acute gastric volvulus is a surgical emergency that requires urgent intervention to prevent gastric ischemia and necrosis. Gastric volvulus manifests as an abnormal rotation or torsion of the stomach and may be associated with gastric outlet obstruction. This pathology can be classified as either mesentero-axial or organo-axial volvulus, depending on the axis of rotation. Similarly, it can be categorized as primary or secondary, depending on the etiology. We describe a case of a 63-year-old female with a history of peptic ulcer disease who presented with severe epigastric pain and vomiting of one-day duration. She was diagnosed with an acute mesentero-axial gastric volvulus, which was successfully reduced using a nasogastric tube.

Pain in the Gut: An Intriguing Case of Toothpick Ingestion Causing Gastric Perforation.

Toothpick ingestion is a medical emergency requiring urgent intervention. Swallowed toothpicks can cause intestinal perforation, bleeding, or damage to the surrounding organs. Herein, we describe a unique case of a geriatric patient with a history of peptic ulcer disease who presented to the emergency department for the evaluation of abdominal pain and nausea. Gastric wall thickening concerning for a gastric neoplasm was observed on a computed tomography (CT) scan of the abdomen and pelvis. An esophagogastroduodenoscopy (EGD) revealed an embedded toothpick with a contained gastric perforation, and the foreign body was retrieved with a grasper device. Given the rare presentation, nonspecific symptoms, inability to recall, and often inconclusive imaging, a high index of suspicion is needed for early diagnosis and treatment of toothpick ingestion.

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.

Gastric Adenocarcinoma of the Remnant Stomach After Roux-en-Y Diagnosed by Endoscopic Ultrasound-Directed Transgastric Endoscopic Retrograde Cholangiopancreatography (EDGE).

It can be difficult to evaluate for pathology with traditional endoscopic modalities following a Roux-en-Y gastric bypass. This is due to the truncated gastrointestinal tract and excluded distal stomach formed during a Roux-en-Y procedure. In these circumstances, a modified endoscopic procedure, known as endoscopic ultrasound (EUS)-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP) (EDGE) is used. Although the Roux-en-Y procedure slightly increases the risk of gastric adenocarcinoma in the general population, the occurrence of gastric adenocarcinoma in the excluded stomach, specifically, is uncommon. Herein, we present a case of gastric adenocarcinoma of the excluded stomach, diagnosed 20 years after a Roux-en-Y procedure. This case is unique because after an extensive five-year workup for melena and iron deficiency anemia, the malignancy was ultimately diagnosed utilizing the innovative EDGE procedure.

Iatrogenic Cushing's From Celiac Plexus Blocks for Chronic Pancreatitis: A Case Report.

Chronic pancreatitis and pancreatic malignancies can result in chronic pain that is difficult to treat with traditional regimens. Various pain management strategies have been implemented to improve the quality of life for patients with these conditions, but these strategies are limited by their efficacy and side effects, including opiate dependence. Celiac plexus blocks (CPB) and celiac plexus neurolysis (CPN) were implemented to decrease opiate dependency and treat chronic pain for pancreatitis and pancreatic malignancy. Numerous approaches are used to facilitate CPB/CPN, including percutaneous, surgical, and endoscopic, guided as computerized tomography (CT), fluoroscopy, ultrasound (US), or endoscopic ultrasound (EUS) techniques. EUS is the latest development in CPB/CPN and the least commonly utilized method; however, it is highly efficacious and associated with minimal complications and/or risks. With endoscopic CPB/CPN, overall mortality improves. Despite the various complications associated with other techniques, no case report or current literature has documented the development of iatrogenic Cushing's disease from the use of steroids during CPB via any approach. Herein, we report the first case of iatrogenic Cushing's disease from CPB in the treatment of chronic pancreatitis. Future studies are warranted to examine the agents used in the chemical destruction for CPB/CPN, to avoid complications such as this.

A Unique Case of Gallbladder Agenesis and Cholangiocarcinoma.

Gallbladder agenesis is a rare congenital anomaly of the biliary tract, due to failure of the gallbladder and cystic duct budding off of the common bile duct during fetal development. Cholangiocarcinoma (CCA) is a malignant tumor arising from the biliary ducts in patients with underlying chronic biliary tract inflammation, primary sclerosing cholangitis, or other diseases. Although few studies have reported cases of cholelithiasis in patients with congenital gallbladder agenesis, there is only one other known case of concomitant cholangiocarcinoma and congenital gallbladder agenesis. Herein we present a case of recurrent gallstones in a male, diagnosed with gallbladder agenesis intraoperatively and with pathology consistent with cholangiocarcinoma.

Endoscopic Treatment of Acute Cholelithiasis Using AXIOS Stenting and Lithotripsy: A Case Series.

The management of gallbladder diseases, including acute cholecystitis and choledocholithiasis, puts a significant strain on healthcare. The first-line treatment for acute cholecystitis is cholecystectomy. Patients who have concomitant choledocholithiasis, large stones, and/or gallstone pancreatitis may also benefit from endoscopic interventions. Endoscopic treatments may also be utilized in patients who are not surgical candidates due to underlying comorbidities. Studies examining the role of endoscopic lithotripsy in concomitant cholecystitis are limited. Herein we present a case series in which an AXIOS stent (Boston Scientific, Marlborough, Massachusetts) was placed into the gallbladder for decompression and utilized to access the gallbladder lumen to perform electrohydraulic lithotripsy in two patients.

A Rare Presentation of Gastrointestinal Stromal Tumor Causing Gastroduodenal Intussusception.

Adult intussusception is exceedingly rare and most commonly occurs in the stomach or ileum. It is less common for adult intussusception to be classified as gastroduodenal, which also carries a higher mortality rate. Adult intussusception usually warrants surgical intervention as the underlying cause is often malignancy. However, rarely, the etiology is a gastrointestinal stromal tumor (GIST). Here, we present the case of a patient who presented with abdominal pain, vomiting, and hemorrhagic shock and was diagnosed with gastroduodenal intussusception secondary to a gastric GIST.

Gastric pneumatosis in immunocompromised patients: A report of 2 cases and comprehensive literature review.

Gastric pneumatosis (GP) is a rare finding. It can be seen with both gastric emphysema (GE) and emphysematous gastritis (EG); however, both conditions present similarly and differentiating between the 2 is difficult radiographically. Moreover, the treatment is vastly different for both conditions, in which treatment for GE is focused on supportive care while treatment for EG may even involve gastrectomy. Making the distinction between GE and EG is crucial because GE has a benign clinical course, while EG carries significant mortality. Early endoscopy may be a useful tool in differentiating between the 2 conditions and to guide further management. Herein, we present a case series of 2 immunocompromised patients who presented with symptoms and radiographic evidence consistent with gastric pneumatosis. We found that early endoscopy assisted in risk stratification and helped guide our management strategy. We recommend consideration of endoscopic evaluation as part of ritualized evaluation of patients presenting with gastric pneumatosis.

Accidental ingestion of an endodontic file: A case report and literary review.

Ingestion and aspiration can be accidental or intentional events in both adults and children. Approximately 1500 people in the United States die from ingestion of foreign bodies annually. Patients with cognitive disabilities, neurological disorders, elderly age or incarcerated patients carry the highest risk of intentional and/or accidental ingestion of foreign objects. Although uncommon, ingestion of foreign objects during dental procedures can be potentially life-threatening and increased awareness is important. Sharp objects ingested from dental procedures can cause impaction, obstruction, hemorrhage, or perforation and may need endoscopic or surgical intervention. Herein we report a case of a 22-year-old male, who underwent routine dental cleaning and accidentally ingested an endodontic file, retrieved from the ascending colon endoscopically without complications.

A Case of a gastropancreatic fistula in the setting of intraductal papillary mucinous neoplasms.

Intraductal papillary mucinous neoplasms (IPMN) are mucin producing tumors which arise from epithelial cells of the main pancreatic duct, pancreatic branch ducts, or both. They are characterized by mucin-producing columnar cells, papillary ductal proliferation, cyst formation, and varying degrees of dysplasia. IPMNs are classified as main duct or branch duct based upon the pancreatic duct anatomy which the IPMN is arising from. Additionally, they can be classified based on their histologic subtypes, which carry varying associations with dysplasia and/or malignancy. Many patients have incidentally identified IPMNs, which are asymptomatic. However, patients may also present with pancreatitis, elevation of liver enzymes, dilation of the pancreatic duct or bile duct as well as distention of the ampullary pancreatic orifice(s), due to impaction and obstruction with mucus. This is known as an endoscopically visualized "fish eye" sign. Patients may also develop exocrine and endocrine pancreatic insufficiency and maldigestion. Some studies also suggest that patients with IPMNs may also be at increased risk for gastric, colorectal, biliary, renal cell, and thyroid malignancies. Rarely, IPMNs can be complicated by fistulation between the main pancreatic duct and neighboring organs. Herein, we present an unusual case of simultaneous fistulation to both the gastric body and the duodenum.

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.

A Case of Multifocal Burkitt Lymphoma in an Immunocompromised Patient.

Non-Hodgkin lymphoma is made from the B-cell lineage and includes extra-nodal marginal lymphomas, follicular lymphomas, mantle cell lymphoma, diffuse large B-cell lymphoma, and Burkitt lymphoma. Burkitt lymphoma is associated with Epstein Barr Virus and Human Immunodeficiency Virus. Although it is common for other B-cell lymphomas to develop in the stomach, it is less common for Burkitt lymphoma tumors to manifest there. Additionally, primary and/or secondary involvement of the duodenum, pancreas, and intestines is very rare in Burkitt lymphoma. Herein, we present a male diagnosed with extensive Burkitt lymphoma of the bone, lymph nodes, pancreas, small intestine, duodenum, and stomach.

A Case of Systemic Mastocytosis Diagnosed Endoscopically.

Mastocytosis, or mast cell proliferation, is very rare. Overall, 60% of patients with systemic mastocytosis (SM) have gastrointestinal involvement, with the colon being the most prevalent affected site. Most patients are diagnosed by bone marrow biopsy. Although gastrointestinal symptoms are common, patients are rarely diagnosed via endoscopy. Indolent SM, which is characterized by both gastrointestinal and cutaneous symptoms in the absence of bone marrow suppression, is extremely rare and often missed due to the complexity of the diagnosis. Here, we present the case of a patient with abdominal pain, flushing, and nausea who was diagnosed endoscopically with SM, likely the indolent type.

Perivesicular Abscess Drainage with Lumen-Apposing Self-Expanding Metal Stents.

Abdominal and pelvic abscesses can occur due to a number of reasons, the most common being surgery. They are associated with significant morbidity and mortality. The treatment approach for these types of collections is often the initiation of broad-spectrum antibiotics, accompanied by drainage. Multiple diagnostic and therapeutic modalities have been described, including; percutaneous, transvaginal, endoscopic, and surgicaldrainage. Due to the complexity of pelvic anatomy, minimally invasive approaches such as percutaneous drainage are usually difficult. Pelvic abscesses have been historically drained through surgery. Endoscopic ultrasound (EUS)-guided interventions have emerged as an alternative for the management of difficult abdominal and pelvic abscesses. Endoscopic interventions have classically included diagnostic and therapeutic aspiration, utilizing drainage catheters with or without placement of plastic stents. More recently, the use of lumen apposing self-expanding metal stents has become a treatment option for deep pelvic abscesses. Lumen opposing metal stents (LAMS) have a saddle-shaped design with two large-diameter flanges on both ends of the stent to anchor the stent edges within the respective lumens as well asa central waist that allows for communication between the two lumens. LAMS were originally designed for transmural pancreatic fluid collection drainage; however,they have been successfully implemented for numerous other off-label uses, including the drainage of pelvic and abdominal abscesses. We present the case of a 34-year-old womanwho presented with a septated abscess located between the urinary bladder and the rectum, which was successfully and definitively drained with LAMS.

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.