Allan L Parker

Safety of band ligator use in the small bowel and the colon

BACKGROUND Endoscopic band ligation for bleeding small-bowel vascular lesions has been reported as safe and efficacious based on small case series. There have been several other published case reports of band ligators used for bleeding lesions, usually Dieulafoys lesions, in the stomach, the proximal small bowel, and the colon. In addition, this method has been used for postpolypectomy bleeding stalks. There has never been a critical look at the anatomic consequences of banding in the thinner sections of bowel. METHOD The purpose of this study is to define the anatomic and histologic consequences of applying band ligator devices to the small and the large bowel. Fresh surgical specimens, both large and small bowel, that were excised because of neoplastic lesions were transported to our endoscopy unit where one end of the intact bowel was sutured shut. A standard upper endoscope was passed via the open end, and the bowel was closed tightly with rubber band ties. The bowel then was insufflated, and band ligators were applied to unaffected mucosa by using a standard technique. Photodocumentation from inside and outside the bowel was obtained. Some of the band polyps were cut above the band, and some were cut below the band in the fresh state. Some were fixed in formalin and examined microscopically. Histologic sectioning occurred at the level of the bands. RESULTS The results were striking in that there were large holes (1 cm) in the fresh ileum specimen. There was gross serosal entrapment manifested by visible puckers on the outer surfaces of the specimens, especially in the small bowel and the right colon. The left colon, anatomically thicker, was less affected. The histologic evaluation revealed inclusion by the band ligator of the muscularis propria and serosa on the small bowel, the muscularis propria in the right colon, and the submucosa in the left colon. CONCLUSIONS Based on these findings, we conclude that band ligator devices are not safe in the small bowel and the right colon but probably are safe in the thicker left colon.

Foley Feeding Catheter Migration into the Small Bowel

Percutaneous endoscopic gastrostomy provides a non-surgical alternative to enteral feeding. The tube may deteriorate or be expelled accidentally from the stomach and require replacement. We report a patient in whom the replacement Foley catheter migrated into the jejunum, resulting in impaction of the hub into the abdominal wall with resultant localized infection and impaction at the stoma site. We review this problem and suggest a simple technique to prevent the complication.

Hepatic Dysfunction as a Paraneoplastic Manifestation of Metastatic Prostate Adenocarcinoma

Cholestasis is a general feature of intrahepatic or extrahepatic biliary obstruction by various mechanisms including cirrhosis, stricture, choledocholithiasis, hepatitis, and neoplasms. Neoplasms can directly impinge on the hepatobiliary tree resulting in bile stasis. Stauffer’s syndrome is another variant of this neoplastic process that can cause cholestasis and liver enzyme elevation without any direct hepatobiliary obstruction, and is thus categorized as a paraneoplastic syndrome of unclear pathophysiology. We report a first case of metastatic prostate adenocarcinoma with features of Stauffer’s syndrome that reversed completely on androgen deprivation therapy. This is in contrast to a previously reported case of Stauffer’s syndrome due to metastatic prostate adenocarcinoma, which reversed partially to androgen deprivation therapy. Our case demonstrates the importance of early recognition of Stauffer’s syndrome and underlying neoplasms in patients who present with cholestasis without clear evidence of intrahepatic or extrahepatic biliary obstruction, which may lead to early initiation of treatment.

Systemic vasculitis presenting with acute gastrointestinal hemorrhage: case report and review of the literature.

The severity of vasculitic disease ranges from distinct clinical symptoms such as mucosal or skin lesions to severe, life-threatening disease. Gastrointestinal hemorrhage is a reported, but uncommon clinical entity. There have been numerous epidemiological studies performed to evaluate the frequency and distribution of the different vasculitides. Although giant cell arteritis is the most common vasculitide, the greatest number of patients that suffer from systemic and gastrointestinal vasculitis are found among patients with rheumatoid arthritis. Approximately 10% of rheumatoid arthritis patients may have a systemic vasculitis. Ten percent of those patients may have gastrointestinal involvement (1). We present a case of systemic vasculitis manifested by gastrointestinal vasculitis with hemorrhage, leukocytoclastic vasculitis, and myonecrosis, without evidence of an identifiable secondary cause.

7145 Endoscopic changes following esophageal dilation in patients with peptic stricture, non-obstructive dysphagia or achalasia.

Esophageal bougie dilation is a technique that is used as an effective strategy to relieve symptomatic peptic strictures and non-obstructive dysphagia. Pneumatic dilation is a primary mode of therapy for patients with achalasia. The goals of this study were as follows: First, to assess the endoscopic changes that occur in the esophageal mucosa following dilation; and second to correlate these changes with clinical efficacy and long-term relief of dysphagia in patients with peptic stricture, non-obstructive dysphagia and achalasia. Methods: Included in the study were patients who received bougie dilation for peptic stricture and non-obstructive dysphagia; and pneumatic dilation for achalasia. Upper endoscopy was initially performed to assess the esophagus and for placement of a Savary guide wire. The bougie esophageal dilations were performed over a Savary guide wire with American dilators. The pneumatic dilations were performed over a Savary guide wire with Microvasive balloons. Following the dilations the esophagogastroduodenoscope was reinserted and advanced to the site of dilation for photodocumentation. Patients were then followed by telephone consultation at two weeks, four weeks and six weeks with the frequency of symptoms recorded. Results: Thirty-one subjects were included in the study during the period of 7/98 to 11/99. There were fourteen women and seventeen men with a mean age of 55.5 (range 19 to 89). The diagnoses were as follows: 11 with peptic stricture, 7 with B-ring, 6 with achalasia, 4 with nonobstructive dysphagia, 1 with mid esophageal web, 1 with anastomotic stricture and 1 was post-Nissen. The mucosal changes following dilation included the following: 8 with increased diameter, 17 with tear, 7 with submucosal hemorrhage, and 12 with blood observed on the dilator. At two, four and six weeks following esophageal dilation, there was improvement in dysphagia (p

Pectus excavatum defect on liver-spleen scintigraphy

A 58-year-old man with a pectus excavatum demonstrated a photon-deficient defect within the left lobe of the liver on liver-spleen scintigraphy using Tc-99m SCOL. Computed tomography of the liver clearly revealed the abnormal defect seen on the liver-spleen scan to be due to the pectus excavatum. This case confirms the impression that these skeletal aberrations may cause false-positive hepatic defects.

Combined common bile duct and gastric outlet obstruction demonstrated during hepatobiliary scintigraphy.

A 64-year-old man presented with jaundice. Hepatobiliary imaging using 99mTc-DISIDA revealed complete hepatobiliary tract obstruction with a photopenic area corresponding to a dilated gallbladder and a large photopenic region corresponding to a distended stomach as a result of gastric outlet obstruction. At surgery, carcinoma of the head of the pancreas was found to be the cause of the combined common bile duct and gastric outlet obstruction.