Brunner's Gland Hyperplasia Causing Complete Small Bowel Obstruction in a Patient With Helicobacter pylori.

Brunner's gland hyperplasia is an uncommon pathology from the duodenum and is believed to be associated with infection with Helicobacter pylori. Patients commonly present with gastrointestinal bleeding, nausea, or abdominal pain. However, obstruction is an unusual clinical finding. A 47-year-old male presented to the emergency department with complaints of recurrent emesis, epigastric pain, and cramping for three days. Medical history was significant for duodenitis and diverticulitis, but there had been no prior abdominal surgeries. Epigastric tenderness to palpation without rebound tenderness was present on physical examination, H. pylori stool antigen was positive on admission, and treatment with triple therapy was initiated. Progressively the patient developed increasing emesis, with an associated cessation in flatus and bowel movements. On endoscopy, it was reported that the endoscope could not advance past the second portion of the duodenum. A nasogastric tube was placed for gastric decompression. Small bowel follow-through showed obstruction at the distal second duodenal segment. Bismuth quadruple therapy was initiated on day three. Push enteroscopy showed luminal narrowing and a transition point at the second duodenal segment with no identifiable mass or significant ulceration. Biopsy reports indicated Brunner's gland hyperplasia. By day seven, the patient reported increased bowel movements and flatus, with a resolution of his nausea and emesis, and the nasogastric tube was removed. The patient was discharged on day eight with outpatient prescriptions for quadruple therapy for six days. He was also instructed to follow up with the general surgery and gastroenterology teams for outpatient colonoscopy six weeks post-discharge and with his primary care physician (PCP) four weeks after completing quadruple therapy to ensure H. pylori eradication. Studies have shown that H. pylori were detected in most patients with Brunner's gland hyperplasia and may induce proliferation in Brunner's glands. Brunner's gland hyperplasia has a low incidence, with minimal cases reported. There is malignant potential but a low risk of progression into adenocarcinoma. Our case reinforces the idea that Brunner's gland hyperplasia should be included in the work-up, alongside testing for infection with H. pylori in assessing patients with gastric obstruction.

Severe Gastrointestinal Bleed Caused by a Rectal Dieulafoy Lesion.

Dieulafoy lesions are vessels that erode the overlying epithelium without the presence of an ulcer. When these lesions bleed, they can frequently be self-limited, but bleeding can be recurrent and prolonged. Although most commonly found in the lesser curvature of the proximal stomach, there are reports of these lesions in other gastrointestinal tract regions. This case identifies a Dieulafoy lesion found in the rectum, which was the source of this patient's profuse rectal bleeding.

A colorimetric method for detection of K-ras codon 12 point mutations in DNA extracted from tissue and peripheral blood in pancreatic disorders.

Molecular-based methods to monitor point mutations require special and expensive equipment unavailable in most hospitals. Colorimetric-based analysis is an ideal platform for K-ras codon 12 gene point mutations because it uses commonly found hospital equipment. The colorimetric assay is sensitive and specific, detecting mutated DNA levels as low as 1% in a wild-type background. Paired genomic DNA extracts of fixed tissue and cellular fractions of peripheral blood are more sensitive and accurate than unpaired samplings. This approach has the potential to improve K-ras point mutation scans as well as to detect micrometastases in circulating tumor cells.

Endoscopic approach to gastric remnant outlet obstruction after gastric bypass: A case report.

BACKGROUND: Acute gastric remnant bleeding is a rare complication of bariatric surgery. Furthermore, acute bleeding from the gastric remnant resulting in gastric remnant outlet obstruction has not been described previously. Endoscopic management of gastric remnant bleed has been challenging due to difficulty accessing the excluded stomach. Traditionally, this necessitates surgical intervention. Recently, however, the adoption of endoscopic ultrasound-directed transgastric intervention provides an alternative approach to management. CASE SUMMARY: A 65-year-old male with a prior gastric bypass presented with the sudden onset of progressive abdominal distension, nausea, and melena of two days duration. His imaging illustrated a massively distended stomach. A nasogastric tube did not result in drainage of fluid or decompression of his abdomen. His endoscopy revealed a normal-appearing gastro-jejunal anastomosis and confirmed the distended "fluid"-filled gastric remnant. An endoscopic ultrasound-directed gastrogastrostomy was created to decompress the gastric remnant. Two liters of blood was suctioned before a large adherent clot was visualized in the gastric antrum. The patient underwent emergent angiography with embolization of the gastroduodenal artery. He was discharged with a stable hemoglobin level and resolution of symptoms. Healing superficial gastric ulcers were visualized on a follow-up endoscopy. Gastric biopsies were consistent with Helicobacter pylori infection for which the patient was treated, and successful eradication was achieved. CONCLUSION: This patient benefited from a timely diagnosis and effective therapy of an acute gastric remnant obstruction from a bleeding ulcer with endoscopic ultrasound-directed transgastric intervention.

A Rare Case of Cytomegalovirus in the Gut in an Immunocompetent Host With Ischemic Colitis.

Cytomegalovirus (CMV) infections are typically seen in individuals with immunosuppressive conditions such as malignancies, HIV/AIDS, and organ transplantation, and in patients on chemotherapy or steroids. Recurrent disease can occur if the virus reactivates due to disruption of immunity due to factors such as older age or immunosuppressive drugs. CMV is common, with a seroprevalence (CMV IgG-positive) of 40-100 % in adults, increasing with age. It has been reported that inflammatory bowel disease in remission can be exacerbated by CMV colitis or complicate steroids refractory colitis flare. For this reason, steroids should be cautiously started if clinical suspicion is high for CMV. We report a unique case of CMV colitis associated with severe ischemic colitis in an immunocompetent patient, with an excellent response to management with antiviral therapy.

Gastrointestinal endoscopy during the coronavirus pandemic in the New York area: results from a multi-institutional survey.

Background and study aims The coronavirus disease 2019 (COVID-19), and measures taken to mitigate its impact, have profoundly affected the clinical care of gastroenterology patients and the work of endoscopy units. We aimed to describe the clinical care delivered by gastroenterologists and the type of procedures performed during the early to peak period of the pandemic. Methods Endoscopy leaders in the New York region were invited to participate in an electronic survey describing operations and clinical service. Surveys were distributed on April 7, 2020 and responses were collected over the following week. A follow-up survey was distributed on April 20, 2020. Participants were asked to report procedure volumes and patient characteristics, as well protocols for staffing and testing for COVID-19. Results Eleven large academic endoscopy units in the New York City region responded to the survey, representing every major hospital system. COVID patients occupied an average of 54.5 % (18 - 84 %) of hospital beds at the time of survey completion, with 14.5 % (2 %-23 %) of COVID patients requiring intensive care. Endoscopy procedure volume and the number of physicians performing procedures declined by 90 % (66 %-98 %) and 84.5 % (50 %-97 %) respectively following introduction of restricted practice. During this period the most common procedures were EGDs (7.9/unit/week; 88 % for bleeding; the remainder for foreign body and feeding tube placement); ERCPs (5/unit/week; for cholangitis in 67 % and obstructive jaundice in 20 %); Colonoscopies (4/unit/week for bleeding in 77 % or colitis in 23 %) and least common were EUS (3/unit/week for tumor biopsies). Of the sites, 44 % performed pre-procedure COVID testing and the proportion of COVID-positive patients undergoing procedures was 4.6 % in the first 2 weeks and up to 19.6 % in the subsequent 2 weeks. The majority of COVID-positive patients undergoing procedures underwent EGD (30.6 % COVID +) and ERCP (10.2 % COVID +). Conclusions COVID-19 has profoundly impacted the operation of endoscopy units in the New York region. Our data show the impact of a restricted emergency practice on endoscopy volumes and the proportion of expected COVID positive cases during the peak time of the pandemic.

Full-thickness resection device (FTRD) for treatment of upper gastrointestinal tract lesions: the first international experience.

Background and study aims The Full-Thickness Resection Device (FTRD) provides a novel treatment option for lesions not amenable to conventional endoscopic resection techniques. There are limited data on the efficacy and safety of FTRD for resection of upper gastrointestinal tract (GIT) lesions. Patients and methods This was an international multicenter retrospective study, including patients who had an endoscopic resection of an upper GIT lesion using the FTRD between January 2017 and February 2019. Results Fifty-six patients from 13 centers were included. The most common lesions were mesenchymal neoplasms (n = 23, 41 %), adenomas (n = 7, 13 %), and hamartomas (n = 6, 11 %). Eighty-four percent of lesions were located in the stomach, and 14 % in the duodenum. The average size of lesions was 14 mm (range 3 to 33 mm). Deployment of the FTRD was technically successful in 93 % of patients (n = 52) leading to complete and partial resection in 43 (77 %) and 9 (16 %) patients, respectively. Overall, the FTRD led to negative histological margins (R0 resection) in 38 (68 %) of patients. A total of 12 (21 %) mild or moderate adverse events (AEs) were reported. Follow-up endoscopy was performed in 31 patients (55 %), on average 88 days after the procedure (IQR 68-138 days). Of these, 30 patients (97 %) did not have any residual or recurrent lesion on endoscopic examination and biopsy, with residual adenoma in one patient (3 %). Conclusions Our results suggest a high technical success rate and an acceptable histologically complete resection rate, with a low risk of AEs and early recurrence for FTRD resection of upper GIT lesions.

Central pancreatectomy without anastomosis.

BACKGROUND: Central pancreatectomy has a unique application for lesions in the neck of the pancreas. It preserves the distal pancreas and its endocrine functions. It also preserves the spleen. METHODS: This is a retrospective review of 10 patients who underwent central pancreatectomy without pancreatico-enteric anastomosis between October 2005 and May 2009. The surgical indications, operative outcomes, and pathologic findings were analyzed. RESULTS: All 10 lesions were in the neck of the pancreas and included: 2 branch intraductal papillary mucinous neoplasms (IPMNs), a mucinous cyst, a lymphoid cyst, 5 neuroendocrine tumors, and a clear cell adenoma. CONCLUSION: Central pancreatectomy without pancreatico-enteric anastomosis for lesions in the neck and proximal pancreas is a safe and effective procedure. Morbidity is low because there is no anastomosis. Long term endocrine and exocrine function has been maintained.

Refeeding Syndrome and Non-Alcoholic Wernicke's Encephalopathy in a Middle-aged Male Initially Presenting with Gallstone Pancreatitis: A Clinical Challenge.

Wernicke's Encephalopathy (WE) is a neurological condition characterized by ophthalmoplegia, ataxic gait, and altered mental status. It is an underdiagnosed yet severely limiting disease process precipitated by thiamine deficiency. Often times, it can occur in conjunction with other disease states like refeeding syndrome in which the underlying etiology is prolonged periods of malnutrition. We present a unique case of non-alcoholic WE in a middle-aged male who initially presented with gallstone pancreatitis complicated with severe metabolic derangements. This ultimately resulted in the development of non-alcoholic WE. Prevention of this condition is a clinical challenge for most physicians as the classic features associated with thiamine deficiency lack diagnostic sensitivity and specificity in critically ill patients. As a result, early recognition and prompt management of this can dramatically decrease morbidity and mortality. Our case highlights and emphasizes the importance of maintaining a high index of suspicion for WE and refeeding syndrome in the setting of altered sensorium and metabolic derangements.

Rare Metastasis of Primary Pancreatic Adenocarcinoma to the Bladder.

Pancreatic cancer commonly metastasizes to the liver, lungs, stomach, bone, and bowel, but rarely does it spread to the bladder. We describe a case of a 66-year-old woman with diabetes mellitus who presented with abnormal liver function laboratory tests, abdominal discomfort, unintentional weight loss, and no urinary symptoms. Abdominal CT revealed a pancreatic and bladder mass. Pathology of the bladder mass confirmed metastatic adenocarcinoma of pancreaticobiliary origin. To our knowledge, this is only the third case of metastatic pancreatic cancer spreading to the bladder since 1953.

Cancer of the Pancreas-Actual 5, 10, and 20+Year Survival: The Lucky and Fortunate Few.

Cancer of the pancreas (CaP) is a dismal, uncommon, systemic malignancy. This article updates an earlier experience of actual long-term survival of CaP in patients treated between 1991 to 2000, and reviews the literature. Survival is expressed as actual, not projected, survival.

Intra-abdominal actinomycosis 11 years after spilled gallstones at the time of laparoscopic cholecystectomy.

A 72-year-old woman with a remote surgical history of a laparoscopic cholecystectomy (LC) complicated by gallstone spillage presented with fever, 3 weeks of nausea and anorexia, and increasing right upper quadrant abdominal pain. After the LC performed 11 years before symptom presentation, the patient was found to have a fluid collection in the right upper quadrant. The patient was asymptomatic at the time, and had no symptoms while being monitored with sequential scans over the next 5 years. At presentation, computed tomography scans revealed a subhepatic, lobulated fluid collection and a radioopacity, consistent with a gallstone, at the inferior aspect of the fluid collection. Subsequent percutaneous drainage of the fluid collection yielded pus that eventually grew Actinomyces israelii. Intravenous clindamycin therapy was initiated, and with further drainage, the abscess resolved. Intra-abdominal abscess formation can present as a delayed complication dropped stones during LC, but these cases usually present within a few years of the procedure. In this case, however, an intra-abdominal abscess formed 11 years after the LC. This extended duration from surgical manipulation to symptom onset is likely secondary to the indolent nature of the infecting organism, A. israelii.

An Overview of the Evolution of Direct Cholangioscopy Techniques for Diagnosis and Therapy.

Direct examination of the biliary tree with endoscopes has been a challenge since endoscopists began performing endoscopic retrograde cholangiopancreatography (ERCP) in the late 1960s. Previously, surgeons had used rigid instruments intraoperatively, which made examination difficult. The first direct cholangioscopy performed by an endoscopist was likely unintentionally done in a patient with postsurgical anatomy. Indirect imaging, ERCP, and percutaneous transhepatic cholangiography are helpful modalities for examining the biliary tree, but they are limited procedures, particularly with regard to the evaluation and treatment of strictures and bile duct stones. This article reviews the history and evolution of direct cholangioscopy since the advent of flexible endoscopes. Additionally, the article describes a new single-operator cholan-gioscopy technique for direct visualization of the biliary tree for diagnosis and intervention. There remains opportunity for innovation as endoscopists strive for safe and less-invasive methods for the identification and treatment of biliary pathology.

Autoimmune Pancreatitis: A Multiorgan Disease Presenting a Conundrum for Clinicians in the West.

Autoimmune pancreatitis (AIP), a clinical entity originally described in East Asia and more recently recognized in the United States and Europe, poses a diagnostic conundrum for clinicians in the West due to immunoglobulin G4 seronegativity. Although expert panels classify this disease into 2 types, it remains difficult to stratify the disease given that both types share most clinical, biochemical, and imaging characteristics. The classic presentation of AIP can mimic that of pancreatic carcinoma, which increases the urgency of evaluation, diagnosis, and treatment. In this article, we elucidate the differences between the 2 types of AIP, highlight the shortcomings of the current classification system, and propose a more inclusive view of the disorder.

Surgery and cancer of the pancreas: will common sense become common practice?

Pancreatic cancer is a systemic disease for most patients. Operations with the intent to cure may be done safely (mortality, < 3%) with shorter hospital stays. Surgery has been minimally effective as a long-term cure. Endoscopic palliation of jaundice is becoming standard practice. Common sense dictates a defined and clear role for surgery (i.e., strict patient selection criteria). Surgery is of great value for small, localized lesions; of clear value as palliative therapy when nonoperative measures fail; and perhaps best applied after neoadjuvant chemoradiotherapy. Surgery is just part of the armamentarium available to treat pancreatic cancer. Novel systemic therapies, including chemotherapy, immunotherapy, and so-called targeted therapies, are becoming increasingly valuable in the management of this systemic disease and are discussed in detail in other articles in this issue.

Choledochoscopy-assisted intraductal shock wave lithotripsy.

In more than 90% of choledocholithiasis cases, endoscopic retrograde cholangiopancreatography with sphincterotomy and stone extraction are successful therapeutic options for clearance of the bile duct with the use of a stone retrieval balloon or basket. However, these techniques fail in a small percentage of patients with biliary stones, and advanced techniques for fragmentation must be used. Intraductal shock wave lithotripsy offers the endoscopist a therapeutic option that may be effective despite the difficulties of a large, impacted stone that cannot be captured by a basket, or a stricture that prohibits delivery of a stone beyond it. This article reviews the use of electrohydraulic lithotripsy and laser lithotripsy in the clinical setting.