Ochsner Journal最新文献

Background: The majority of ingested foreign bodies are uneventfully expelled through the gastrointestinal tract. However, anatomically narrowed areas in the proximal gastrointestinal tract create sites of increased retention/impaction of ingested foreign bodies. Foreign body impaction in the esophagus poses a medical emergency because of the complications associated with delayed management: esophageal perforation, infection, and fistula formation. Thus, urgent endoscopic intervention to remove sharp esophageal foreign bodies is necessary.

Case report: A 45-year-old male presented with a 3-day history of a foreign body in the esophagus. Esophagogastroduodenoscopy identified a horizontally lodged V-shaped fishbone with both lateral edges deeply embedded in the esophageal mucosa. When endoscopic removal using traditional removal accessories failed, endoscopic scissors were used to fracture the spinous process edge of the fishbone, and the fishbone was advanced into the gastric lumen. A makeshift endoscope hood was fashioned from a sterile glove, attached to the distal end of the endoscope, and used to remove the fishbone.

Conclusion: The off-label use of endoscopic scissors to relieve the proximal esophageal obstruction by fracturing the fishbone was integral in achieving successful removal.

Background: Mixed neuroendocrine non-neuroendocrine neoplasms (MiNENs) are rare tumors of the gastrointestinal tract with neuroendocrine and non-neuroendocrine components. Ampullary MiNENs are extremely rare, with few cases reported to date.

Case report: A 41-year-old male was diagnosed incidentally with a dilated common bile duct and intrahepatic biliary radicles while being evaluated for right ureteric calculi. Contrast-enhanced computed tomography scan of the abdomen showed a mass in the ampullary region with a positive double duct sign. Side-viewing endoscopy indicated an ampullary growth, and biopsy confirmed adenocarcinoma. The patient underwent total robotic pancreatoduodenectomy with an uneventful postoperative course. His final histopathologic examination revealed a tumor with 2 components, each of which accounted for at least 30% of the tumor: a neuroendocrine tumor and an adenocarcinoma with signet ring cells. The patient received adjuvant chemotherapy and at 1-year follow-up showed no evidence of recurrence.

Conclusion: Ampullary MiNENs are rare composite gastroenteropancreatic tumors characterized by histologic heterogeneity; they can be effectively treated with robotic pancreatoduodenectomy. The more aggressive component of the MiNEN should be considered when determining an adjuvant therapy.

Background: Wernicke encephalopathy-an uncommon and severe condition caused by thiamine deficiency-is most often associated with alcohol use but can occur in other settings of nutrient deficiency. Posterior reversible encephalopathy syndrome is an acute neurologic condition characterized by reversible subcortical vasogenic edema that is often associated with hypertension. We present the case of a patient with concurrent Wernicke encephalopathy and posterior reversible encephalopathy syndrome.

Case report: A 26-year-old female with a surgical history of laparoscopic sleeve gastrectomy performed 4 months prior presented with ataxia, confusion, bilateral blurred vision, and headache. Initial examination showed reduced visual acuity (20/200 in both eyes), ophthalmoplegia, high-frequency bilateral upbeat and mild horizontal nystagmus, bilateral optic disc swelling with disc hemorrhage, and intraretinal hemorrhages. She was found to have thiamine deficiency resulting in Wernicke encephalopathy, as well as bilateral frontal, parietal, and occipital T2 hyperintensities on magnetic resonance imaging consistent with posterior reversible encephalopathy syndrome. After treatment with pulse dose thiamine repletion and antihypertensives, the patient improved clinically, with increased visual acuity (20/30 in both eyes) and complete resolution of bilateral optic disc edema and intraretinal hemorrhages. However, upbeat nystagmus remained.

Conclusion: Neuro-ophthalmic signs may be early indicators of Wernicke encephalopathy and posterior reversible encephalopathy syndrome, underscoring the vital role of eye care providers in recognizing these conditions, particularly in patients who have undergone bariatric surgery. Without a high index of suspicion, Wernicke encephalopathy may be overlooked in these patients.

Background: Adhesive capsulitis, also known as frozen shoulder, is a challenge to treat clinically. Common first-line treatment options are suprascapular nerve block (SSNB), intra-articular corticosteroid (IACS) injection, hydrodilatation, and physical therapy. This literature review summarizes each of these conservative treatments and discusses the evidence base for combining treatment options for potential additive benefits to improve patient outcomes (ie, pain, range of motion [ROM], and shoulder function). Methods: The PubMed and Google Scholar databases were searched using the search terms "adhesive capsulitis," "frozen shoulder," "corticosteroids," "physical therapy," "suprascapular nerve block," "hydrodilatation," and "conservative care." Pertinent articles were identified and synthesized to provide a comprehensive review of 4 common conservative treatments for adhesive capsulitis. Results: Combining SSNB with physical therapy and/or IACS injection and combining IACS injection with physical therapy have support in the literature for improving shoulder pain, ROM, and function, while hydrodilatation and physical therapy seem to offer some additive benefits for improving shoulder ROM when used as adjunct treatments for adhesive capsulitis. Conclusion: Adhesive capsulitis remains a challenge to treat clinically with much still unknown regarding treatment optimization. For the foreseeable future, first-line conservative management will continue to be the mainstay of managing adhesive capsulitis. Thus, knowing how to best use and optimize these various options-both individually and in combination-is vital for effective treatment.

Background: Acute decompensated heart failure accounts for more than 1 million hospitalizations in the United States every year. Beta-blockers are a first-line agent for patients experiencing heart failure with reduced ejection fraction, but beta-blocker use in patients hospitalized for acute decompensated heart failure remains low. We conducted an analysis of the existing evidence and guidelines to determine the conditions for prescribing beta-blockers to patients with acute decompensated heart failure. Methods: We searched the PubMed database for studies from 2004 to 2024 that included the search terms "beta blockers" and "acute decompensated heart failure." We included studies in which beta-blockers were used in patients with heart failure with reduced ejection fraction and excluded studies that did not study beta-blockers directly. We compiled recommendations from professional societies regarding beta-blocker usage-both for outpatients with heart failure with reduced ejection fraction and for patients hospitalized with acute decompensated heart failure. Results: Studies consistently demonstrated lower rates of mortality and rehospitalization when beta-blocker therapy was maintained for patients with heart failure with reduced ejection fraction who were already on beta-blocker therapy. Conversely, withdrawal of beta-blocker therapy was associated with increased in-hospital and short-term mortality. We summarized our findings in a guideline-based flowchart to help physicians make informed decisions regarding beta-blocker therapy in patients with acute decompensated heart failure. Based on the evidence, beta-blockers should be initiated at a low dose in patients with heart failure with reduced ejection fraction who have never been on beta-blockers, provided the patient is hemodynamically stable. Conclusion: Our research and our guideline-based flowchart promote guideline-directed use of beta-blockers to improve the outcomes of patients with heart failure with reduced ejection fraction.