Ahmed Abdel Samie

Detection and management of spontaneous intramural small bowel hematoma secondary to anticoagulant therapy.

Intestinal hematoma, once considered a rare complication of anticoagulation, has recently been increasingly reported. Spontaneous small bowel hematomas most commonly involve the jejunum, followed by the ileum and duodenum. They occur in patients who receive excessive anticoagulation with vitamin K antagonists or who have additional risk factors for bleeding. Diagnosis can be readily identified with sonography and confirmed with computed tomography. Early diagnosis is crucial as most patients can be treated successfully without surgery. Conservative treatment is recommended for intramural intestinal hematomas, when other associated complications needing laparotomy have been excluded.

Biliary-Pancreatic Endoscopic and Surgical Procedures in Patients under Dual Antiplatelet Therapy: A Single-Center Study.

Background/Aims Dual antiplatelet therapy has to be used for at least 1 month after placement of bare metal coronary stents and for a minimum of 1 year after placement of drug eluting stents. Because of the higher risk of bleeding, guidelines strongly recommend to delay elective surgery until dual antiplatelet therapy is ended. However, no data are available regarding the bleeding risk in patients on combined aspirin/clopidogrel therapy undergoing surgical or high-risk endoscopic procedures. Methods We retrospectively analyzed the medical reports of patients on dual antiplatelet therapy, the patients who had to undergo emergency biliary-pancreatic surgery or endoscopic retrograde cholangiography with endoscopic sphincterotomy while in our unit between January 2009 and July 2012. Results In our series, biliary-pancreatic surgical and endoscopic procedures were safely performed in 11 consecutive patients on dual antiplatelet therapy with no evidence of bleeding. Conclusions In emergency, surgical and high risk endoscopic procedures may be performed in patients on dual antiplatelet therapy.

A Rare Cause of Obstructive Jaundice

uestion: An 80-year-old woman was admitted to the ospital because of jaundice, upper abdominal pain, nauea, and vomiting. The patient was on phenprocoumon or chronic atrial fibrillation. Physical examination reealed right upper quadrant tenderness and jaundice. Laboratory studies revealed abnormal coagulation tests ith a prolonged prothrombin time (International Normalzed Ratio 6.0) and a prolonged activated partial thromoplastin time ( 110 seconds). Furthermore, her liver hemistry tests were abnormal with total bilirubin at 12 g/dL, alanine aminotransferase at 170 U/L, aspartate

Fully covered self-expandable metal stents for treatment of malignant and benign biliary strictures

AIM To present a series of covered self-expandable metal stents (CSEMS) placed for different indications and to evaluate the effectiveness, complications and extractability of these devices. METHODS We therefore retrospectively reviewed the courses of patients who received CSEMS due to malignant as well as benign biliary strictures and post-sphincterotomy bleeding in our endoscopic unit between January 2010 and October 2011. RESULTS Twenty-six patients received 28 stents due to different indications (20 stents due to malignant biliary strictures, six stents due to benign biliary strictures and two stents due to post-sphincterotomy bleeding). Biliary obstruction was relieved in all cases, regardless of the underlying cause. Hemostasis could be achieved in the two patients who received the stents for this purpose. Complications occurred in five patients (18%). Two patients (7%) developed cholecystitis, stents dislocated/migrated in other two patients (7%), and in one patient (3.6%) stent occlusion was documented during the study period. Seven stents were extracted endoscopically. Removal of stents was easily possible in all cases in which it was desired using standard forceps. Twelve patients underwent surgery with pylorus preserving duodenopancreatectomy. In all patients stents could be removed during the operation without difficulties. CONCLUSION Despite the higher costs of these devices, fully covered self-expanding metal stents may be suitable to relief biliary obstruction due to bile duct stenosis, regardless of the underlying cause. CSEMS may also represent an effective treatment strategy of severe post-sphincterotomy bleeding, not controlled by other measures.

Fully Covered Self-Expandable Metal Stents for Treatment of Both Benign and Malignant Biliary Disorders

Transpapillary stents are increasingly being used for biliary strictures, whether benign or malignant. However, there are different stent types and available data is controversial. Recently, completely covered self-expandable metal stents (CSEMSs) have been proposed as an alternative therapeutic option in different biliary indications, including strictures of the distal bile duct, anastomotic stenosis after orthotopic liver transplantation, bile duct leaks, periampullary perforation following endoscopic sphincterotomy (ES), and postsphincterotomy bleeding. Despite the higher costs of these devices, fully covered self-expanding metal stents seem to be a suitable therapeutic option to relief biliary obstruction due to bile duct stenosis, regardless of the underlying cause.

An Elderly Patient on Warfarin With Rectal Bleeding

Question: An 83-year-old woman was admitted to the hospital with rectal bleeding. She complained about pain in her lower back ecause of a heavy fall at home 2 weeks before. Owing to atrial fibrillation and low cardiac output, she had been under constant reatment with phenprocoumon. On rectal examination, a soft mass was felt dorsal on supine position. Laboratory studies revealed abnormal coagulation tests ith a prolonged prothrombin time (international normalized ratio, 2.5) and a slightly prolonged partial thromboplastin time of 8 seconds (normal, 24 –36). The platelet count was within the normal range, and her serum creatinine was elevated (4 mg/dL). ecause of severe anemia (hemoglobin, 7.5 g/dL), she received a pack of red blood cells. Ileocolonoscopy revealed massive diverticulosis of the entire colon and a 3-mm opening to the dorsal rectal wall with discharge f blood (Figure A). Computed tomography without contrast enhancement because of impaired renal function was performed, evealing a 7 7-cm round, liquid mass (Figure B) that could also be demonstrated by rectal endosonography (Figure C). Correlating her clinical and imaging findings, what is your diagnosis? Look on page 270 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Gallensteinileus bei Sigmastenose infolge rezidivierender Sigmadivertikulitis – eine seltene Komplikation des Gallensteinleidens

ZusammenfassungHintergrund:Der Gallensteinileus ist eine seltene Komplikation des Gallensteinleidens und eine ungewöhnliche Ursache für die intestinale Obstruktion. Etwa 1–4% aller mechanischen intestinalen Obstruktionen sind durch Impaktion eines oder mehrerer Gallensteine bedingt. Die klinischen Symptome eines Gallensteinileus sind meist unspezifisch.Fallbeschreibung:Eine 82-jährige Patientin wurde mit krampfartigen rechtsseitigen Oberbauchschmerzen und Zeichen eines Dickdarmileus aufgenommen. Anamnestisch war eine rezidivierende Sigmadivertikulitis bekannt. Sonographisch zeigten sich eine Aerobilie und eine ausgeprägte Sigmadivertikulitis mit Ileuszeichen. In der endoskopischen retrograden Cholangiographie stellte sich ein breiter Kontrastmittelaustritt über die Gallenblase in das rechtsseitige Kolon dar. Im Computertomogramm konnten zwei Tonnensteine mit einem Durchmessser von ca. 3 cm, die das Lumen des Sigmas weitgehend verlegten, festgestellt werden. Bei gesichertem Gallensteinileus erfolgte ein chirurgischer Eingriff mit Cholezystektomie, Revision der biliokolischen Fistel und Sigmaresektion.Schlussfolgerung:Dieser Fall zeigt, dass relative Engen des Sigmas nach rezidivierender Divertikulitis eine Prädilektionsstelle für die Impaktion von Fremdkörpern sein können. Der Gallensteinileus stellt nach wie vor eine seltene, aber wichtige Differentialdiagnose bei Patienten mit dem Bild eines mechanischen Ileus dar. Dieses seltene Krankheitsbild kann bei entsprechendem klinischem Verdacht sonographisch und computertomographisch diagnostiziert werden. Die Therapie ist in der Regel chirurgisch, allerdings sind die Komplikationsraten einer chirurgischen Therapie hoch, da die meisten Patienten mit diesem Krankheitsbild höheren Alters sind und häufig eine Vielzahl von Begleiterkrankungen aufweisen. Die definitive Therapie sollte individuell dem Patienten und den entzündlichen Veränderungen der cholezystoenteralen Fistel angepasst werden.AbstractBackground:Gallstone ileus is a rare complication of cholelithiasis and an uncommon cause of intestinal obstruction. It accounts for about 1–4% of all mechanical bowel obstructions. The clinical symptoms and signs of gallstone ileus are mostly nonspecific.Case Report:An 82-year-old woman with recurrent diverticulitis of the sigmoid was admitted because of cramping right upper abdominal pain and signs of large bowel obstruction. Abdominal ultrasound revealed pneumobilia and severe diverticulitis of the sigmoid with signs of ileus. Endoscopic retrograde cholangiography visualized the cholecystoenteric fistula. In addition, computed tomography (CT) scan revealed two stones 3 cm in diameter leading to nearly complete obstruction of the sigmoid. The patient underwent an open cholecystectomy, closure of the cholecystoenteric fistula, and sigmoidectomy.Conclusion:This case report demonstrates that relative stenoses of the sigmoid due to recurrent diverticulitis may predispose to the impaction of foreign bodies. Gallstone ileus is a rare but important differential diagnosis of intestinal obstruction. Ultrasound and CT scans are very helpful in diagnosing gallstone ileus. The treatment is surgical. Unfortunately, surgical therapy of this rare complication is associated with a high morbidity and mortality rate due to multiple comorbidities and age-related problems of these patients. The management of patients with gallstone ileus should be individualized.BACKGROUND Gallstone ileus is a rare complication of cholelithiasis and an uncommon cause of intestinal obstruction. It accounts for about 1-4% of all mechanical bowel obstructions. The clinical symptoms and signs of gallstone ileus are mostly nonspecific. CASE REPORT An 82-year-old woman with recurrent diverticulitis of the sigmoid was admitted because of cramping right upper abdominal pain and signs of large bowel obstruction. Abdominal ultrasound revealed pneumobilia and severe diverticulitis of the sigmoid with signs of ileus. Endoscopic retrograde cholangiography visualized the cholecystoenteric fistula. In addition, computed tomography (CT) scan revealed two stones 3 cm in diameter leading to nearly complete obstruction of the sigmoid. The patient underwent an open cholecystectomy, closure of the cholecystoenteric fistula, and sigmoidectomy. CONCLUSION This case report demonstrates that relative stenoses of the sigmoid due to recurrent diverticulitis may predispose to the impaction of foreign bodies. Gallstone ileus is a rare but important differential diagnosis of intestinal obstruction. Ultrasound and CT scans are very helpful in diagnosing gallstone ileus. The treatment is surgical. Unfortunately, surgical therapy of this rare complication is associated with a high morbidity and mortality rate due to multiple comorbidities and age-related problems of these patients. The management of patients with gallstone ileus should be individualized.

Endoscopic biliary sphincterotomy in patients under antithromboembolic therapy

Background Endoscopic sphincterotomy (EST) carries several risks (e. g., pancreatitis and bleeding). The risk of bleeding is increased in patients with a compromised coagulation system, often due to antithromboembolic therapy. Recent guidelines caution to perform endoscopic procedures that carry a high risk of bleeding in these patients. However, data to support current recommendations are scarce, and EST frequently has to be performed as an emergency procedure. Therefore, it was the aim of our retrospective study to evaluate the rate of procedural bleeding in patients undergoing EST in our endoscopy unit while on antithromboembolic therapy. Methods Between March 2005 and August 2015, 1798 consecutive patients underwent EST at HELIOS Hospital in Pforzheim, Germany. Concomitant therapy with anticoagulants and/or antiplatelet agents was noted, and bleeding following sphincterotomy was recorded. Results We observed 54 bleeding events in 1482 patients (3.6 %) without and 20 events in 316 patients (6.3 %) with antithromboembolic therapy. Bleeding was recorded in 7 out of 123 patients (5.7 %) taking aspirin, in one out of 34 patients (2.9 %) taking clopidogrel, and in 12 out of 209 patients under heparin (5.7 %). Compared to controls, no statistically significant increase in the bleeding rate was seen. However, we observed an association between a lower physical health score and increased bleeding rate. If precut was necessary for biliary tract access, the bleeding rate increased significantly (p < 0.01). Conclusion Bleeding following EST is neither increased in patients taking clopidogrel and/or aspirin or heparin and rarely requires transfusion of packed red blood cells nor does it lead to an increased mortality. However, bleeding following EST seems to occur more frequently in patients with a compromised health status or following precut of the papilla.

A Patient with a Solitary Lump in the Sigmoid Colon

Question: A 73-year-old male underwent screening colonoscopy. He has lived for a couple of years in Namibia on his farm and has gone several times on hunting safaris in other African countries. He was not aware of any serious diseases in the past except for fever for 2–3 days and a rash on his back and chest during one of his safaris in Zambia. Colonoscopy was performed on an outpatient basis and documented normal findings except for a 2-cm mass in the distal sigmoid with a normal-appearing mucosa on narrow band imaging (Figure A, B). The mass felt quite firm on touch with a biopsy forceps. Histology showed massive subepithelial eosinophilic cell infiltration (Figure C) as well as granuloma (Figure D). Considering the patient’s history, what is your diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Leiomyosarcoma of the Sigmoid Colon: a Rare Cause of Intestinal Intussusception

Gastrointestinal stromal tumours (GISTs) represent the most common mesenchymal neoplasms in the gastrointestinal tract. However, prior to the recent developments in immunohistochemical diagnostic tools, most GISTs were misdiagnosed as leiomyosarcoma [1]. Lately, leiomyosarcoma is recognised as an extremely rare tumour of the gastrointestinal tract. Because of different treatment options and prognoses, differentiation of both tumour entities based on histological and immunohistochemical criteria is crucial [2].