Explore the vast range of titles available.

Endoscopic ultrasound is a useful diagnostic and interventional device for gastroenterologists. Although extremely useful, endoscopic ultrasound is not a benign tool. Possible complications of endoscopic ultrasound include hemorrhage, infection, and perforation. Although rare, iatrogenic small bowel perforations have been reported largely on the duodenum and rarely on the jejunum or ileum. Traditionally, these iatrogenic small bowel perforations have been managed with open surgery. However, recent emerging clinical data has revealed that immediate endoscopic treatment may be a feasible and safe alternative to surgery in select cases. Here, we describe the endoscopic management of an iatrogenic jejunal perforation during a linear endoscopic ultrasound examination managed successfully using an endoscopic clip.

Endoscopic necrosectomy has emerged as the preferred treatment modality for walled-off pancreatic necrosis. This study was designed to evaluate the safety and efficacy of direct endoscopic necrosectomy with and without hydrogen peroxide (H2O2) lavage. Retrospective chart reviews were performed for all patients undergoing endoscopic transmural management of walled-off pancreatic necrosis at 9 major medical centers from November 2011 to August 2018. Clinical success was defined as the resolution of the collection by imaging within 6 months, without requiring non-endoscopic procedures or surgery. Of 293 patients, 204 met the inclusion criteria. Technical and clinical success rates were 100% (204/204) and 81% (166/189), respectively. For patients, 122 (59.8%) patients had at least one H2O2 necrosectomy (H2O2 group) and 82 (40.2%) patients had standard endoscopic necrosectomy. Clinical success was higher in the H2O2 group: 106/113 (93.8%) vs 60/76 (78.9%), P = 0.002. On a multivariate analysis, the use of H2O2 was associated with higher clinical success rate (odds ratio 3.30, P = 0.033) and earlier resolution (odds ratio 2.27, P < 0.001). During a mean follow-up of 274 days, 27 complications occurred. Comparing procedures performed with and without H2O2 (n = 250 vs 183), there was no difference in post-procedure bleeding (7 vs 9, P = 0.25), perforation (2 vs 3, P = 0.66), infection (1 vs 2, P = 0.58), or overall complication rate (n = 13 [5.2%] vs 14 [7.7%], P = 0.30). H2O2-assisted endoscopic necrosectomy had a higher clinical success rate and a shorter time to resolution with equivalent complication rates relative to standard necrosectomy.See the visual abstract at http://links.lww.com/AJG/B714.(Equation is included in full-text article.).

Foreign body (FB) ingestion is a common occurrence in the United States with a reported incidence of 120 per 1 million people, accounting for up to 1500 fatalities annually. The majority of FB ingestions will pass through the gastrointestinal tract spontaneously, while in 10% to 20% of patients, intervention will be necessary. A variety of endoscopic devices can be utilized to facilitate FB removal from the gastrointestinal tract, including snares, retrieval nets, and grasping forceps. We report the case of a 58-year-old female who required utilization of endoscopic scissors for FB removal in the setting of multiple failed attempts with traditional methods. This case highlights a novel approach to gastric FB removal utilizing endoscopic scissor forceps, which should be considered in select cases to further improve the efficacy of endoscopic FB removal and reduce the need for surgical intervention.

INTRODUCTION:Endoscopic necrosectomy has emerged as the preferred treatment modality for walled off pancreatic necrosis (WON). Standard endoscopic necrosectomy can be tedious and time consuming, employs sharp instruments in vascular cavities, and does not provide for microdebridement. Hydrogen peroxide (H2O2) lavage has been reported in small series; however, there have been no comparative studies on its safety and efficacy in the management of WON.METHODS:We performed a retrospective chart review of all cases undergoing endoscopic transmural management of WON at 9 major medical centers in the US from November 2011 to August 2018. Cystogastrostomies were performed using lumen apposing metal stents (LAMS). Patients who underwent cystogastrostomy without necrosectomy were excluded. Clinical success was defined as resolution of the WON by imaging within 6 months, without requiring non-endoscopic drainage procedures or surgery.RESULTS:A total of 296 patients underwent cystgastrostomy and 206 patients underwent one or more necrosectomies. Clinical success was achieved in 171/192 (89.1%) of those with follow-up data at 6 months. In terms of patients, 122 (59.2%) patients had at least one H2O2 necrosectomy (H2O2 group), and 84 (40.8%) patients had standard endoscopic necrosectomy. Clinical success was higher in the H2O2 group (n = 107 (95.5%) vs 63 (79.7%), P < 0.001). On multivariate logistic regression, the use of hydrogen peroxide (OR 17.4, 95% CI: 2.9–103, P = 0.002) was associated with higher clinical success rates (Table 2). During a mean follow up of 278 days, 29 complications occurred: bleeding (n = 18), perforation (n = 5), respiratory complication (n = 3), and sepsis (n = 3). One death was presumed to be procedure related (splenic pseudoaneurysm rupture day 8; standard necrosectomy group). A total of 394 necrosectomies were performed. Comparing necrosectomy procedures with and without H2O2 (n = 209 vs 185), there was no difference in procedure time (72.5 ± 39.6 vs 72 ± 44.2, P = 0.936), post-procedural bleeding (8 vs 10, P = 0.45), perforation (3 vs 2, P = 1), infection (1 vs 2, P = 0.6) or overall complication rate (n = 15 (7.1%) vs 14 (7.6%), P = 1) (Table 3).Table 1Baseline characteristics and procedural outcomes: Any H2O2 vs standardTable 2Odds ratio of predictors of Clinical SuccessTable 3Comparison of outcomes of necrosectomy procedures with and without hydrogen peroxideCONCLUSION:In this multicenter retrospective cohort study, H2O2 necrosectomy appeared to be safe and effective with a higher clinical success rate and equivalent rates of bleeding, perforation, death, and overall complications relative to standard necrosectomy.

Background: Coil migration can occur after embolization of the gastrointestinal (GI) tract, and although it is usually a benign complication, it has infrequently been reported to be life threatening. We present a case of coil migration after embolization of the gastroduodenal artery (GDA) and discuss its management. Case Report: A 68 year old male presented with ongoing melena and a hemoglobin (Hgb) of 9.7 g/dL, decreased from a baseline of 13.2 g/dL. Endoscopy found a 2 x 3 cm non obstructing cratered ulcer without active bleeding in the duodenal bulb. No intervention was performed given the ulcer's size. Interventional radiology (IR) was consulted as Hgb fell to 6.7 g/dL. A CT arteriogram demonstrated a pseudoaneurysm of the distal GDA. Mesenteric arteriography revealed a pseudoaneurysm of the mid and distal GDA. Embolization of the distal GDA with helical coils and gel-foam slurry was performed by IR using a \"sandwich technique.\" The patient received a total of 3 units of pRBC's and his Hgb stabilized at 8.4 g/dL upon discharge. Two months later, follow up endoscopy showed a well healed ulcer with coil penetration through the mucosa of the duodenal bulb. The patient was asymptomatic and hemodynamically stable without signs of peritoneal and systemic infection. Patient was further discharged with routine follow up. Discussion: GI hemorrhage secondary to rupture is the most common clinical presentation of GDA aneurysms (52%) while only 7.5% of them remain asymptomatic.The mortality of rupture is 40%, thus requiring interventioni. Endoscopy often fails to successfully achieve hemostasis so embolization using helical coils or a gel-foam slurry may be required. The placement of coils can infrequently lead to migration through the mucosa. The mechanism of penetration is thought to be due to inflammation and fistula formation in the lumen, which may require further IR intervention or open surgical repair in hemodynamically unstable patients. Our patient was stable and asymptomatic and therefore monitored with routine follow. Several techniques exist for endovascular coil retrieval in cerebral vasculature however literature on the management of migrated coils in visceral artery aneurysms is scant. Endoscopic removal with forceps under fluoroscopic guidance has been discussed, but there are no data regarding outcomes of this technique. This case emphasizes the need for further studies in the management of coil migration.

Behcet's Disease (BD) is a chronic vasculitic condition that affects multiple parts of the body including the GI system. In a patient with odynophagia, abdominal pain, and bowel ulcerations the differential includes Inflammatory Bowel Disease, Colon Cancer, or BD. This case highlights the varied presentation of BD and the challenges associated with its diagnosis and management. A 28-year-old Chinese man presented to the ENT clinic with chronic odynophagia since 2014. Two laryngoscopies, one in 2014 and one in 2017, revealed a posterior pharynx ulceration (Figure A) that improved with anti-inflammatories and steroids. In 2017, he concurrently endorsed abdominal pain accompanied by a decrease in bowel movements. There was no blood or mucus in the stool, nor any unintentional weight loss. Upon gastroenterology evaluation, abdominal exam was benign. Labs: ESR 36 mm/hr, CRP 34.3 mg/L. Stool O&P was negative. EGD revealed chronic gastritis with antral biopsy positive for H. pylori, which was treated. Colonoscopy was notable for a large nearly-circumferential cecal ulcer (Figure B) with biopsy initially suggestive of Entamoeba histolytica. However, final pathology failed to definitely identify the amebic organisms. He was treated with metronidazole and paromomycin due to the unclear etiology, though repeat colonoscopy yielded no improvement in the cecal ulceration. A pathergy skin test was positive (Figure C), linking the intestinal and pharyngeal ulcers to a diagnosis highly suggestive of BD. He was initiated on a course of prednisone and azathioprine with improvement. We present a case of a patient who was initially suspected of having invasive amoebiasis, but was found to have intestinal BD. The disease is rare with a higher prevalence in Asia and the Middle East with about 13.5 to 35 cases per 100,000. Factors such as younger age of diagnosis, higher CRP level, and volcano-type ulcers are suggestive of poorer prognostic features. Though there is no gold standard therapy for BD, treatment is similar to that of Crohn's disease. Therapy involves a prolonged course of immunosuppression with steroids in addition to azathioprine, or initiation of TNF-alpha inhibitors in refractory cases. In a patient with abdominal pain and oropharyngeal and intestinal ulceration, maintaining a broad differential is key in delineating between conditions with clinically similar presentations. Suspect BD in a patient with recurrent ulcerations and positive pathergy test.

Introduction: Current radiologic and endoscopic studies for pancreatic cystic lesions have known poor sensitivity and accuracy for distinguishing any particular cystic lesion. The current case describes the use of two novel EUS-guided tools for the diagnosis and management of a large, symptomatic pancreatic cyst. Case Description: 30 year old female with prior history of pancreatitis presented with left upper quadrant abdominal pain. MRCP revealed a large 28 mm x 39 mm unilocular cyst in the tail of the pancreas. Based on the history, the possibility of a pancreatic pseudocyst was raised. However, given the patient's young age and female gender, as well as the cyst morphology and location, a clinical suspicion was raised for a possible mucinous cystic neoplasm (MCN). Given the diagnostic uncertainty, and the vast differences in management of these lesions, the decision was made to perform further diagnostic testing to help guide management. EUS evaluation with multimodality sampling was performed. nCLE imaging revealed multiple thickened epithelial bands lining the cyst wall. Four biopsies were then obtained using the MFB. Following this, FNA was performed. Seventeen ml of dark brown watery fluid was obtained. Cyst fluid analysis demonstrated glucose 1,500 ng/ml, amylase 11,859 u/L. Cytology revealed foamy macrophages and a few clusters of bland glandular cells. MFB pathology yielded tissue with ovarian-like stroma with mucinproducing epithelial lining consistent with an MCN. The patient was referred for a distal pancreatectomy. Final surgical pathology revealed the cyst wall to be lined by flat cuboidal epithelium and ovarian-type stroma without cytologic atypia, papillary architecture or epithelial proliferation. Final diagnosis favored an endometrial cyst of the pancreas over an atypical MCN. The patient had resolution of her symptoms following surgery. Discussion: Standard EUS-FNA and cyst fluid analysis are suboptimal in their ability to make a cytopathologic diagnosis of a pancreatic cyst. In the current case, standard biochemical fluid analysis produced conflicting results showing both an elevated cyst fluid CEA and amylase, and thus unable to distinguish an inflammatory pseudocyst from a neoplastic or non-inflammatory cystic lesion. Cyst fluid cytology was similarly non-diagnostic. However, the combined use of EUS-guided nCLE and MFB produced highly detailed diagnostic information allowing for appropriate management. Watch the video: https://goo.gl/XkPkfy