Advances in Digestive Medicine最新文献

Luminal strictures along the endoscopic retrograde cholangiopancreatography (ERCP) route to the papilla to allow for biliopancreatic endoscopy may be encountered in individual patients, precluding scope advancement. Stent implantation to allow for scope passage followed by successful through-the-scope ERCP has rarely been reported in such setting, however, to the best of our knowledge neither in terms of pancreatic indications and/or as same-session endoscopic ultrasound-ERCP, which is pioneered in this report.

A 74-year-old male with a history of diabetes and Parkinson's disease presented to our hospital due to progressive dysphagia for 3 months. He also had frequent choking and been admitted to another hospital due to pneumonia before visiting our hospital. He had a surgery of anterior cervical discectomy and fusion (ACDF) 16 years ago due to osteomyelitis with myeloradiculopathy. Cervical roentgenograms showed migrated plate-locking screws, indicating malposition of fixation screw over C7-T1 (Figure 1A). Esophagogastroduodenoscopy was performed to assess the progressive dysphagia (Figure 2).

What is the diagnosis of this patient?

The esophagogastroduodenoscopy revealed a screw head had eroded into the esophageal lumen. The exam was stopped promptly to avoid possible complications due to air inflation. Computed tomography of the neck disclosed focal gas accumulation in the esophagus at the C7 level just anterior to the plate. The screw had penetrated through to the esophageal lumen (Figure 1B).

The incidence of esophageal perforation after ACDF was low (<1%).¹ The symptoms of esophageal perforation after ACDF includes dysphagia (57%), neck swelling and/or discharge (21%), pneumonia (11%), odynophagia, sore throat (7%), hoarseness, and breathing difficulty (7%).² The diagnosis of esophageal perforation related to ACDF is based on esophagogastroduodenoscopy, upper gastrointestinal series, or esophagogram.

Most delayed pharyngoesophageal perforations occurred less than 1 year from the time of ACDF. Vrouenraets reported a case of esophageal perforation 9 years post-ACDF with a background of chronic esophagitis.³ Our patient experienced this complication 16 years after the surgery. This time frame is the longest ever reported in the literature. Clinicians should consider this differential diagnosis when managing patients with dysphagia and a history of ACDF. Computer tomography or upper GI series should be performed before esophagogastroduodenoscopy if cervical roentgenograms showed malposition of plate-locking screws.

Chia-Chang Chen: The endoscopist who performed the esophagogastroduodenoscopy, final approval and drafting of the manuscript. Chih-Chi Tsai: Final approval and drafting of the manuscript. Yen-Chun Peng: Final approval of the manuscript.

The authors declare no conflict of interest.

Written informed consent was obtained from the patient.

Gallbladder cancer is the fifth most frequent women cancer in Algeria. Squamous-cell and adenosquamous carcinomas are the rarest histological type of this cancer and represent less than 7%. Malformation of the bile ducts such as a choledochal cyst or a biliopancreatic maljunction are risk factors for this cancer. This manuscript reports a rare case of an 82-year-old woman operated on for an adenosquamous carcinoma of the gallbladder associated with a bile duct cyst and a biliopancreatic junction abnormality. Aggressive surgery was performed combined with adjuvant oral chemotherapy. Twenty-nine months of recurrence-free survival was achieved by this patient suffering from this aggressive and rare form of gallbladder cancer.

Due to poor patient condition and the high risk associated with the procedure, colonoscopy is rarely performed in the intensive care unit (ICU). It is indicated for ICU patients with suspected ischemic colitis, decompression of colonic distension, or lower gastrointestinal hemorrhage. ICU patients usually have more co-morbidities and higher mortality rates than other inpatient patients. Data in the literature regarding the outcomes of ICU patients after colonoscopy are limited. The aim of this study was to identify factors that are predictive of outcomes following colonoscopy in ICU patients. We retrospectively analyzed the medical records and imaging findings of patients who underwent colonoscopy in an ICU setting between January 2018 and June 2020. A total of 79 patients were identified and enrolled for analysis. The median age of the patients was 78 years. The colonoscopy findings included angiodysplasia (n = 3, 3.8%), colitis (n = 17, 21.5%), colonic ulcer (n = 2, 2.5%), diverticulosis (n = 3, 3.8%), hemorrhoid (n = 10, 12.7%), rectal ulcer (n = 16, 20.3%), tumor (n = 10, 12.7%), volvulus (n = 1, 1.3%), bleeding of unknown origin (n = 4, 5.1%), and no diagnosis (n = 13, 16.5%). A total of 46 patients (58%) survived to discharge. Patients who survived had statistically significantly higher Glasgow coma scale (GCS) scores (P = .009) and albumin levels (P = .002) than patients who did not survive. Patient survival is associated with GCS score and albumin level, but not with colonoscopy findings.

Splenic artery pseudoaneurysm (SAP) is a rare but potentially fatal complication of acute pancreatitis. We present a 67-year-old female with ruptured SAP as a complication of acute pancreatitis. The patient had mild clinical symptoms on admission, thus was difficult to identify for severe complications. However, she had experienced two episodes of hypovolemic shock on the 10th day after admission. Abdominal computer tomography scan and angiography revealed evidence of splenic artery injury possibly due to acute pancreatitis. The patient underwent transcatheter embolization of splenic artery and total spleen. However, she was still hemodynamically unstable and eventually expired due to severe sepsis. This case raised our clinical awareness of SAP as a rare but life-threatening complication of acute pancreatitis even in patients with short clinical courses and initially mild symptoms. SAP should be kept in mind during image study or in hemodynamically unstable cases of acute pancreatitis.

Massive low gastrointestinal bleeding is an uncommon but severe event. Dieulafoy's lesion is a rare cause of gastrointestinal bleeding but associated with a high mortality rate. In this report, we describe two cases of massive low gastrointestinal bleeding due to Dieulafoy's lesion of the colon who were successfully treated with endoscopic therapy, despite severe bleeding with inadequate bowel preparation. These two cases emphasize the importance of careful endoscopic evaluation to investigate gastrointestinal bleeding and that rare entities should be considered in the differential diagnosis of common clinical presentations.

Langerhans cell histiocytosis (LCH) is a rare histiocytic neoplasm. The clinical presentation and the disease extension are variable. LCH may involve a single site, multiple sites within a single system, or multiple systems. Gastrointestinal tract involvement is rare and most often observed in children with multisystem disease. Adult patients with gastrointestinal tract involvement are extremely rare, and only a few cases have been reported. We present a 45-year-old man with LCH presenting as a submucosal solitary colonic lesion.

Mixed neuroendocrine-non-neuroendocrine neoplasms (MiNENs) of the ampulla of Vater are extremely rare. We present a case of a MiNEN of the ampulla of Vater and review the literature related to management and treatment recommendations. A 72-year-old woman presented with Charcot's triad for a week. Computed tomography revealed a periampullary tumor. Endoscopic retrograde cholangiopancreatography with internal drainage and sphincterotomy with biopsy revealed mixed adenocarcinoma-neuroendocrine carcinoma. Ampullary MiNEN with an American Joint Committee on Cancer (8th edition) TNM classification of Stage IIIA T3bN1M0 was diagnosed, and the Whipple procedure was performed. Both components of the tumor were of high grade, each component accounting for approximately 50% of the tumor. FOLFOX (oxaliplatin + de Gramont) was prescribed as adjuvant chemotherapy. No recurrence was noted at the 3-month follow-up. Diagnosis of MiNENs through biopsies is challenging, and core biopsies should be suggested when a surgical sample is unavailable. Although heterogeneous, MiNENs are usually highly aggressive neoplasms, contributing to the dissemination of metastases and poor prognosis. In conclusion, radical resection is the optimal treatment choice for almost all potentially curable cases. In addition, treatment strategies for patients with a new diagnosis of MiNENs of the ampulla of Vater should be formulated after discussions in multidisciplinary meetings and should be based on the most aggressive and predominant component in the diagnostic sample.

Barrett's esophagus (BE), a complication of gastroesophageal reflux disease (GERD), is derived from prolonged gastric acid or bile exposure to the esophagus.^{1, 2} This refluxate may lead to erosions and chronic inflammatory cells infiltration in the esophageal mucosa. Prolonged damage in healthy squamous epithelium in esophagus would promote its replacement with intestinal metaplasia containing goblet cells, that is, BE. BE is considered as a premalignant lesion for esophageal adenocarcinoma (EAC).² EAC is the predominant form of esophageal cancer in Western countries with progressively increased incidence.³ BE can have neoplastic transformation from low-grade dysplasia (LGD), high-grade dysplasia (HGD), to EAC.² The prognosis of advanced esophageal cancer is poor, while the survival is excellent if detected at early stages for early intervention.^{3, 4} Therefore, it is extremely important to detect dysplasia or early EAC during surveillance endoscopy in BE patients.

Seattle protocol is recommended for endoscopic surveillance in BE patients. It is suggested to perform random biopsies at four quadrants every 1 to 2 cm of the Barrett's segment for detecting subtle dysplasia.⁵ Modern enhanced imaging technologies have been developed to improve dysplasia detection beyond the traditional high definition—white light endoscopy (HD-WLE). Update guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) suggest using dye-based or virtual chromoendoscopy to detect target lesion for biopsies identified in Barrett's segment.⁵ In a systemic review involving 14 studies with over 800 patients, chromoendoscopy would show a 34% increase in yield in detecting dysplasia or cancer compared with WLE, irrespective of dye-based or virtual.⁶ Nevertheless, ASGE did not recommend chromoendoscopy as a replacement for the Seattle protocol but rather as an adjunct technique.⁵

Several dyes, including acetic acid, methylene blue, and indigo carmine, are the dyes commonly used to detect Barrett's dysplasia in surveillance. Acetic acid is the only dye-based chromoendoscopy that fulfill the ASGE preservation and incorporation of valuable innovations (PIVI) thresholds (sensitivity 96.6%, negative predictive value 98.3%, specificity 84.6%).^{5, 7} However, the dye application in BE surveillance is hampered by increased cost for special dye spraying equipment, dye preparation, increased procedure time, potential risk of including DNA damage, and difficulty in adequate dye application evenly.⁵ Because of these limitations, virtual chromoendoscopy may be the preferred, advanced imaging technique for BE surveillance.

Virtual chromoendoscopy applied light filters, emitting light with a short wavel