Borko Nojkov

Gastrointestinal bleeding from Dieulafoy’s lesion: Clinical presentation, endoscopic findings, and endoscopic therapy

Although relatively uncommon, Dieulafoys lesion is an important cause of acute gastrointestinal bleeding due to the frequent difficulty in its diagnosis; its tendency to cause severe, life-threatening, recurrent gastrointestinal bleeding; and its amenability to life-saving endoscopic therapy. Unlike normal vessels of the gastrointestinal tract which become progressively smaller in caliber peripherally, Dieulafoys lesions maintain a large caliber despite their peripheral, submucosal, location within gastrointestinal wall. Dieulafoys lesions typically present with severe, active, gastrointestinal bleeding, without prior symptoms; often cause hemodynamic instability and often require transfusion of multiple units of packed erythrocytes. About 75% of lesions are located in the stomach, with a marked proclivity of lesions within 6 cm of the gastroesophageal junction along the gastric lesser curve, but lesions can also occur in the duodenum and esophagus. Lesions in the jejunoileum or colorectum have been increasingly reported. Endoscopy is the first diagnostic test, but has only a 70% diagnostic yield because the lesions are frequently small and inconspicuous. Lesions typically appear at endoscopy as pigmented protuberances from exposed vessel stumps, with minimal surrounding erosion and no ulceration (visible vessel sans ulcer). Endoscopic therapy, including clips, sclerotherapy, argon plasma coagulation, thermocoagulation, or electrocoagulation, is the recommended initial therapy, with primary hemostasis achieved in nearly 90% of cases. Dual endoscopic therapy of epinephrine injection followed by ablative or mechanical therapy appears to be effective. Although banding is reportedly highly successful, it entails a small risk of gastrointestinal perforation from banding deep mural tissue. Therapeutic alternatives after failed endoscopic therapy include repeat endoscopic therapy, angiography, or surgical wedge resection. The mortality has declined from about 30% during the 1970s to 9%-13% currently with the advent of aggressive endoscopic therapy.

Safety and efficacy of ERCP after recent myocardial infarction or unstable angina

BACKGROUND ERCP after myocardial infarction (MI) or unstable angina (UnA) can potentially entail significant cardiovascular risks. OBJECTIVE To analyze the safety of ERCP after MI or UnA. DESIGN Retrospective study. PATIENTS Adult patients less than 30 days after MI or UnA. SETTING Three hospitals from 1985 to 2010, encompassing 7600 ERCPs. INTERVENTIONS ERCP. MAIN OUTCOME MEASUREMENTS ERCP diagnosis, therapy, efficacy, and complications. RESULTS Thirteen patients (mean age 77.9 ± 11.4 years) underwent ERCP on average 6.9 ± 7.7 days after MI. ERCP indications were suspected choledocholithiasis/gallstone pancreatitis (n = 10); cholangitis (n = 7); obstructive jaundice with suspected pancreatic mass (n = 1); and biliary stent removal/replacement (n = 2). ERCP revealed choledocholithiasis (n = 8); previous stent (n = 2); and nonpathologic findings (n = 3). Therapies included balloon sweep (n = 11), sphincterotomy (n = 8), visible stones extracted by balloon sweep (n = 8), and biliary stent placement/replacement/removal (n = 3). Two mild complications occurred: hypotension during ERCP successfully treated with ephedrine and obstructing periampullary clot successfully removed at repeat ERCP. Eleven patients subsequently did well (mean hospital discharge 6.5 days after ERCP); 1 patient with metastatic ovarian cancer remained ventilator dependent, and another patient with multiple comorbidities had a fatal pulmonary embolus 10 days after ERCP. Six patients underwent ERCP 7.5 ± 5.2 days after UnA for suspected choledocholithiasis (n = 5) and bile duct injury (n = 1). ERCP findings included choledocholithiasis (n = 3), cystic duct leak (n = 1), ampullary stenosis (n = 1), and nonpathologic findings (n = 1). Sphincterotomy was performed in 5 patients, visible stones were extracted by balloon sweep in 3, and a biliary stent was inserted in 1. One mild complication occurred: hypotension during ERCP which was successfully treated with ephedrine. All 6 patients were discharged (mean 8.0 days after ERCP). LIMITATIONS Small study size; retrospective study. CONCLUSIONS This study suggests that therapeutic ERCP involves acceptable risks when performed soon after MI or UnA for suspected choledocholithiasis or other therapeutic indications and may be performed in such situations when strongly indicated.

Random Colonic Mucosal Biopsies During Colonoscopy Performed for Chronic Diarrhea: Differences in Practice Patterns Between Gastroenterologists and Surgeons in a Study of 300 Patients

Random Colonic Mucosal Biopsies During Colonoscopy Performed for Chronic Diarrhea: Differences in Practice Patterns Between Gastroenterologists and Surgeons in a Study of 300 Patients

Endoscopic hemoclips to immediately close gastric perforation from a failed attempt at PEG in a morbidly obese patient.

A serious, immediate complication of percutaneous endoscopic gastrostomy (PEG), associated with morbid obesity, that was successfully treated by endoscopic hemoclips is reported. A 52-year-old, morbidly obese woman (body mass index [BMI] 1⁄4 35.6 kg/m) without prior abdominal surgery or gastrointestinal diseases was referred for PEG after tracheostomy for prolonged ventilator-dependent respiratory failure after admission for diabetic ketoacidosis. Before this admission, she had refused referral for bariatric surgery for her morbid obesity associated with diabetes mellitus and hypertension. Esophagogastroduoderoscopy (EGD) during PEG revealed no gastrointestinal abnormalities. The PEG site was identified in the distal gastric body by transillumination and manual external pressure. PEG was performed conventionally by passing a catheter through abdominal/gastric walls into gastric lumen, passing a guidewire through the catheter, grasping the guidewire by endoscopic snare, and pulling the guidewire outside the mouth. A 20 French PEG tube (EndoVive Standard PEG kit, Boston Scientific, Spencer, IN) was tied to the guidewire and pulled through the mouth, into gastric lumen and through the gastric wall, but became stuck in the thick abdominal wall fat. The PEG tube could not be delivered anterograde through the skin, despite an adequately-sized skin incision, using multiple attempts at

Colonic endometriosis presenting as a sigmoid stricture requiring laparoscopic colonic surgery for diagnosis and treatment.

Colonic endometriosis may be difficult to diagnose because it is relatively uncommon [1, 2], may present without stereotypic findings of symptoms related to menstruation [3], and may not be diagnosable by colonoscopy with superficial colonoscopic biopsies when endometrial implants are deep within the colonic wall [4]. An unusual case is reported in which a patient developed progressively more severe constipation leading to obstipation from partial colonic obstruction that went undiagnosed for more than 1 year despite extensive abdominal tests, including abdomino-pelvic CT, colonoscopy, and an initial laparoscopy; the etiology was definitively diagnosed as partial mechanical obstruction from colonic endometriosis after repeat laparoscopy with resection of a sigmoid stricture. This case report with literature review illustrates the potential difficulty in establishing this diagnosis, especially by colonoscopy, when endometrial lesions are deep within the colonic wall; the potential for a missed diagnosis at an initial laparoscopy; and the potential requirement for a second laparoscopy for diagnosis and treatment.