Video Journal and Encyclopedia of GI Endoscopy最新文献

Background

Esophageal introital stenosis is common in patients who receive radiation therapy for laryngeal and hypopharyngeal cancers. Infrequently, complete obstruction develops within the esophageal introitus.

Patient and methods

In this video manuscript, we present a case of complete introital obstruction in which flexible endoscopic therapy was successfully by performing combined antegrade and retrograde endoscopy (CARE) and pharyngo-esophageal puncture using guide wire (PEP-guide wire), in combination with balloon dilation.

Results

Esophageal lumen patency was re-established with “CARE PEP-guide wire” method without complications.

Conclusions

In patients with complete esophageal introital obstruction, CARE PEP based approach can potentially re-establish the esophageal introital patency.

Background

Percutaneous endoscopic gastrostomy (PEG) tube placement is a commonly performed procedure in patients requiring medium to long term enteral feeding and with impaired swallowing. The PEG tract and stoma usually close spontaneously after PEG tube removal. Infrequently, gastrocutaneous fistula develops.

Patients and methods

In this video manuscript, the author reviews and demonstrates different endoscopic management options in approaching gastric fistula: mechanical approximation using through-the-scope endoclips or over-the-scope clipping devices; percutaneous trans-abdominal suture placement; and plugging the fistula tract with biodegradable materials or other tissue adhesives.

Conclusions

Health care providers need to be aware of this uncommon complication after PEG tube removal and management it with appropriate minimally invasive options where expertise and devices are available. Currently, tissue approximation with clips, intra-gastric and/or trans-abdominal suture placement is the preferred endoscopic options for fistula closure.

Background

Gastrointestinal bleeding with origin in ectopic varices occurs in 1–5% of all portal hypertension-related bleeding episodes in the context of liver cirrhosis.

Patient and methods

We report the case of a 45-years-old patient with liver cirrhosis due to chronic hepatitis C who was admitted to the emergency department for melena with 1 day of evolution. Endoscopy revealed the presence of fresh blood in the stomach and duodenum. Although there were no visible esophageal or gastric varices, there was a large varix in the second portion of duodenum with a clear rupture point. Endoscopic injection of a total of 1 ml of N-butyl-2-cyanoacrylate mixed with 1 ml of lipiodol was performed intravariceally, which resulted in the collapse of the varix indicating a complete interruption of its blood supply. Follow-up CT scan showed the injected N-butyl-2-cyanoacrylate eradicating the duodenal varix at the second portion of the duodenum.

Result

The patient was discharged one week after the endoscopic therapy and, 7 months after this episode, remains without hemorrhagic recurrence.

Conclusions

The presented case supports endoscopic injection sclerotherapy with N-butyl-2-cyanoacrylate as a treatment option for ruptured duodenal varices that, despite being a rare event, when it occurs, is often fatal.

Background

Colonic volvulus is a loop of bowel twisted around the site of mesenteric attachment leading to bowel obstruction. The sigmoid colon is involved in a majority of these cases. If untreated, sigmoid volvulus leads to bowel ischemia, perforation, sepsis, and potential death.

Patients and methods

In this video manuscript, we present two patients with uncomplicated sigmoid volvulus that were successfully managed by emergent endoscopic decompression, detorsion, and reduction (EDDR) and temporary colon decompression tube placement as a bridge therapy to elective and definitive surgical interventions. Detailed endoscopic evaluation and techniques are described. In addition, classic radiological findings such as the “coffee bean” sign on plain radiograph and the “whirl” sign on computed tomography are shown.

Results

After successful EDDR with subsequent bowel preparation and medical resuscitation, both patients underwent elective surgical resection of the sigmoid colon with primary anastomosis without post-operative complications.

Conclusions

Sigmoid volvulus is a medical emergency and diagnosis requires a high index of suspicion. Emergent EDDR and decompression tube placement should be utilized as a first line treatment for patients with uncomplicated sigmoid volvulus.

Barrett׳s Esophagus (BE) is an important premalignant condition that predisposes to adenocarcinoma and there is evidence that the extent of the Barrett׳s segment correlates with the risk of malignancy. The extent of the endoscopic findings is described by the Prague classification using the Prague C & M criteria (C is the circumferential length and M is the maximal length). The purpose of these criteria is to simplify and standardize endoscopic characterization of the extent and length of BE.

Background and aims

The histopathologic features of rectal neuroendocrine tumors (NETs), including size, lymphovascular invasion, invasion of proper muscle, and mitotic rate, have a limited role to play in determining a treatment plan preoperatively. We aimed to investigate the morphologic parameters associated with metastasis, and to evaluate their predictive value.

Methods

Between January 2000 and May 2011, the medical records and endoscopic findings of 468 patients presenting with rectal NETs at the Samsung Medical Center were analyzed retrospectively. All tumors were classified according to size and endoscopic features such as color, shape, contour, and surface change.

Results

Twenty-one of the 468 patients (4.5%) with rectal NETs had lymph node (LN) metastasis and 11 patients (2.4%) had distant metastasis. Risk factors for metastasis included tumor size (≥10 mm in diameter), hyperemic change, polypoid lesions, irregular contours, and surface ulceration (p=0.000). Independent risk factors that were predictive of metastasis on multivariate analysis included tumor size (≥10 mm in diameter), hyperemic change, and surface ulceration. As the number of independent risk factors for metastasis increased, the risk of metastasis rose.

Conclusions

Endoscopic features such as hyperemic change, polypoid lesions, irregular contours, and surface ulcers with tumor size ≥10 mm in diameter are associated with metastasis in rectal NETs. In particular, atypical endoscopic features including hyperemic change, and surface ulcer with tumor size ≥10 mm in diameter may help to predict the risk of metastasis of rectal NETs.

Background

Aortoenteric fistula is a communication between the aorta and adjacent bowel. It is rare, potentially fatal, and is difficult to diagnose and manage. These patients often present with a “herald bleed,” followed by massive gastrointestinal hemorrhage.

Patient and methods

A 67 year old man presented with right upper quadrant pain, hematochezia and hypotension. Two months ago, the patient underwent elective open repair of an abdominal aortic aneurysm. On upper endoscopy, fresh blood and adherent clots were seen in the third/fourth portion of the duodenum. After some of the clots were gently washed off with water flushing, a fistula opening was seen on posterior superior wall of the duodenum. The fistula opening was surrounded by edematous duodenal mucosal. An aortoenteric fistula was highly suspected and the patient went to emergent laparotomy.

Results

During surgery, significant inflammation was noted surrounding the aorta with friable tissues of the aorta itself. A definite aortoenteric fistula was seen arising in the native aorta. Unfortunately, the patient expired due to cardiac vascular collapse.

Conclusions

Diagnosis of aortoenteric fistula requires a high index of suspicion and careful history-taking. Endoscopic findings include adherent clots or bleeding at the fistula opening and/or eroded vascular graft or stent into the bowel.