Estela Mogrovejo

Endoclips to Facilitate Cannulation and Sphincterotomy During ERCP in a Patient with an Ampulla Within a Large Duodenal Diverticulum: Case Report and Literature Review

Cannulation and sphincterotomy of the ampulla may be technically challenging at endoscopic retrograde cholangiopancreatography (ERCP) when the ampulla is located within a duodenal diverticulum because of obscuring of the ampulla and approaching it from an awkward angle. Successful application of endoclips to expose and facilitate cannulation of an ampulla within a duodenal diverticulum has been reported for three cases of diagnostic ERCP [1, 2] and one case of therapeutic ERCP [3]. A second case is hereby reported of clinically beneficial, successful, therapeutic ERCP using endoclips.

Case Report of Patient Presenting in Shock from Band Penetration into Stomach After LAGB Surgery: Diagnosis by Emergency EGD After Misdiagnosis by Abdominal CT.

About 250,000 bariatric surgeries, including about 50,000 laparoscopic adjustable gastric band (LAGB) surgeries, are performed annually in the USA, to reduce weight and consequently reduce morbidity and mortality from morbid obesity [1]. Band penetration/perforation into the stomach is a rare complication of LAGB surgery [2]. Comprehensive literature review of cases in which this diagnosis was documented by endoscopic photographs reveals scant data on endoscopic features of this complication [3–9]. Patients often present with moderate symptoms and signs after band penetration perhaps because the penetrating band forms a tight barrier that prevents peritoneal leakage. A case is reported that extends the clinical spectrum of band penetration/perforation, by 1—reporting a patient presenting in shock from overwhelming sepsis and profound GI bleeding from band penetration/perforation; 2—illustrating that an attending radiologist may miss the sometimes subtle CT findings of band penetration; and 3—further characterizing the endoscopic findings.

Primary Duodenal Aspergillosis in a Patient With Alcoholic Cirrhosis and Poorly Controlled Diabetes Mellitus

A 74-year-old recovering alcoholic man presented with progressively increasing epigastric pain for 2 months. The patient had a prior medical history of Child-Pugh Class A alcoholic cirrhosis and esophageal varices, gastric ulcer diagnosed 4 years earlier with documented endoscopic healing of the ulcer after 6 weeks of omeprazole therapy (40 mg/d), and poorly controlled diabetes with a recent hemoglobin A1c level of 9.2%. He had never received corticosteroids or other immunosuppressive therapy and was HIV seronegative. At the time of presentation, he reported nausea and a 10-kg weight loss. Physical examination revealed epigastric tenderness without rebound tenderness. Abdominal computed tomography revealed periduodenal edema. Esophagogastroduodenoscopy revealed duodenitis, a 25-mm ulcer in the descending duodenum, and a 10-mm bulbar ulcer, without stigmata of recent hemorrhage (Figure 1). Histological examination of ulcer biopsies revealed duodenal inflammation and necrotic debris (Figure 2). Grocott’s methenamine silver stain revealed fungal organisms with hyphal forms, highly consistent with Aspergillus. Immunohistochemistry was negative for Helicobacter pylori. Chest x-ray and computed tomography of the sinuses did not reveal evidence of invasive aspergillosis. The patient was treated with voriconazole 100 mg/d for 6 weeks and omeprazole 40 mg twice a day. Repeat esophagogastroduodenoscopy, 4 months later, revealed healed ulcers with minimal scarring. Repeat biopsies demonstrated normal duodenal mucosa without Aspergillus. The patient died 18 months later from liver failure, without recurrent aspergillosis.

Consideration of endoclips to help cannulate an ampulla hidden in a duodenal diverticulum at ERCP.

We thank Drs. Nadir and Chuang for their thoughtful letter [1] in response to our recent single case report [2] of successful deployment of two endoclips at ERCP to expose an ampulla of Vater, initially inaccessible due to the ampulla lying within a large diverticulum, with consequent successful cannulation, sphincterotomy, and stone retrieval. They report one case in which an endoclip was deployed to evert and expose an ampulla that was initially inaccessible within a large duodenal diverticulum, and deployed a second endoclip for stabilization that inadvertently caused greater instability of the ampulla. Despite this difficulty, they were able to use the sphincterotome to evert the ampullary opening and successfully cannulate for therapeutic ERCP. We have two comments. First, despite their difficulties, the outcome was successful cannulation after multiple unsuccessful attempts before deploying the endoclips. Second, we experienced a similar problem of instability during cannulation after deploying one endoclip which resolved after deploying a second endoclip. This finding argues for carefully placing endoclips to achieve stability. Endoclips should currently be considered only when (1) cannulation is otherwise impossible due to ampulla location within a diverticulum, (2) ERCP is required for potentially life-saving endoscopic therapy, and (3) the endoscopist is highly skilled in both ERCP and endoclip deployment. This technique should currently be considered experimental with use restricted to these circumstances due to insufficient outcomes data.

Comment on Parikh et al.

To the Editor: We read with great interest the article by Parikh et al. (1). The authors performed a retrospective review comparing patients having an ERCP on a weekend or delaying it until Monday and found a significant difference in the length of stay and a trend toward decreased cost associated with weekend ERCP.

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

Portal vein thrombosis after colectomy for ulcerative colitis: two case reports and proposed novel pathophysiology for this association.

Dear Sir: We read the interesting article by Papay et al.1 on venous thromboembolic events (VTEs) in inflammatory bowel disease (IBD), including 4 cases of portal vein thrombosis (PVT) among 2811 IBD patients, recently published in the Journal. While the association of VTEs with IBD is well established, PVT has been rarely reported in association with ulcerative colitis (UC).2 We report two new cases and propose a novel pathophysiology for this association. A 30-year-old woman with chronic UC, developed a flare refractory to all medical therapies, including infliximab. Abdomino-pelvic CT, with oral and intravenous contrast, revealed no PVT (Fig. 1A—preoperative). Laparoscopic total abdominal proctocolectomy, with diverting ileostomy, was performed. She was …