Hiren Vallabh

EUS-directed transgastric ERCP (EDGE) with use of a 20-mm × 10-mm lumen-apposing metal stent in a patient with Roux-en-Y gastric bypass

re 1. A, MRCP showing marked intrahepatic and extrahepatic biliary ductal dilation with abrupt cutoff of the mid common bile duct. B, EUS image ing insertion of 19-gauge EUS needle into the excluded stomach. C, EUS image of contrast material and sterile water being injected through 19-gauge needle to distend the excluded stomach. D, EUS image of 20-mm 10-mm electrocautery-enhanced lumen-apposing metal stent (LAMS) inserted the gastric remnant through the gastric pouch, creating a gastrogastric fistula. E, Endoscopic image confirming placement of the proximal flange of AMS within the gastric pouch. F, Ampulla visualized by duodenoscope. G, Cholangiogram demonstrating distal stricture of the common bile duct ) with upstream dilation of the CBD up to 15 mm. H, Fluoroscopic image of placement of a 10F 7-cm plastic biliary stent.

Got milk? Endoscopic removal of ingested milk carton

A 26-year-old man with a history of depression and recurrent foreign body ingestions was admitted for acute onset of epigastric abdominal pain after he had ingested a milk carton. The patient admitted to intentionally swallowing an entire 16-ounce milk carton. He detailed that he had emptied the milk carton and folded the paperboard into a cylindrical object, which he was able to successfully ingest. He then presented to the emergency department, where our service was consulted for endoscopic removal of the foreign body. Using a 29F endoscope (GIF-HQ190, Olympus America, Center Valley, Penn), we were able to visualize the paperboard milk carton, which had fully expanded into form in the body and cardia of the stomach (Fig. 1A). Because of the large size of the object, we were unable to retrieve it using rat-tooth forceps or even a 27-mm snare. We decided to use an argon plasma coagulation (APC) catheter with

Endoscopic and Pathologic Resolution of Chronic Nonsteroidal Anti-Inflammatory Drug-Induced Diaphragm-Like Colonic Strictures and Ulceration

The chronic use of nonsteroidal anti-inflammatory drugs (NSAIDs) has steadily increased and, as a result, adverse effects have become more common. Isolated case reports have documented diaphragm-like colonic strictures and ulceration as the result of NSAID use. We report a unique case of this rare side effect with documented endoscopic and histologic healing of multiple proximal diaphragm-like colonic strictures and ulceration months after simple discontinuation of NSAID therapy.

A Severe Case of Ipilimumab-Induced Ileocolitis Refractory to Glucocorticosteroids and Infliximab

Ipilimumab is a monoclonal antibody that works as an immunotherapeutic agent through selective targeting of T cells to strengthen the response to metastatic melanoma. It is well known that this pharmaceutical agent can cause the adverse effect of colitis. We report a rare presentation of ileocolitis refractory to both glucocorticosteroids and infliximab with a resultant pneumatosis and perforation requiring subtotal colectomy and end ileostomy.

Endoscopic use of oxidized regenerated cellulose and topical thrombin: a novel approach for control of bleeding pancreatic pseudocyst wall after endoscopic cystgastrostomy

re 1. A, EUS view of 7-cm pancreatic pseudocyst. B, EUS view showing deployment of an AXIOS cystgastrostomy stent in a pancreatic pseudocyst. C, scopic view of pancreatic tissue with active bleeding and an overlying clot through a cystgastrostomy stent. D, Endoscopic view through cystgasomy stent after placement of Surgicel oxidized regenerated cellulose. E, Endoscopic view through cystgastrostomy stent after placement of Surgicel ecothrom topical thrombin. F, Endoscopic view through cystgastrostomy stent 48 hours after treatment showing resolution of bleeding. G, Endoic view of stomach after cystgastrostomy stent removal.

Removal of migrated biliary stent by use of an enteral stent in a patient with gastric outlet obstruction caused by nonresectable pancreatic adenocarcinoma with prior loop gastrojejunostomy

re 1. A, Coronal plane of CT view of abdomen and pelvis with and without intravenous contrast medium showing migrated biliary stent in the secto third portion of the duodenum. B, Fluoroscopic scout film of migrated biliary stent in the right upper quadrant of the abdomen. C, Endoscopic of duodenal bulb obstruction with intubation by a tandem catheter. D, Fluoroscopic view of duodenum confirming successful passage of guidewire, ation of duodenal stricture with a tandem catheter, and contrast medium filling the lumen adjacent to migrated biliary stent. E, Fluoroscopic view of yed duodenal stent over duodenal stricture and adjacent migrated biliary stent. F, Endoscopic view of migrated biliary stent being removed with ratforceps through a deployed duodenal stent. G, Fluoroscopic view showing only duodenal stent and confirming removal of migrated biliary stent.

Simultaneous passage of ultra-slim colonoscope and colonic stent catheter across left-sided colonic stent for placement of a hepatic flexure stent for malignant large-bowel obstruction

re 1. A, CT coronal view of abdomen and pelvis without contrast medium showing transition point (arrow) at the hepatic flexure concerning for -bowel obstruction. B, Endoscopic view of descending colon stent placement. C, Endoscopic view of colonic stent catheter and ultra-slim colonoe across the descending colon stent. D, Endoscopic view of stent deployment across hepatic flexure stricture. E, Abdominal radiographic view of the tic flexure and descending colon stents after the procedure.

Preventing second laparoscopic procedure by use of a novel technique to allow removal of biliary stent in a patient with Roux-en-Y gastric bypass

re 1. A, Balloon dilation up to 15 mm of the fibrotic gastrostomy tube tract. B, Old biliary stent protruding through the ampulla in second portion of uodenum. C, Fully covered esophageal stent deployed across gastrostomy tube tract. D, Balloon dilation up to 20 mm of the gastrostomy tube tract gh esophageal stent. E, Successful removal of biliary stent. F, Cholangiogram with no further bile leak.

Novel Use of an Endoscopic Suturing Device to Repair a Cholecystoduodenal Fistula

A 50-year-old woman with a history of uncomplicated Crohn’s disease presented for esophagogastroduodenoscopy (EGD) for evaluation of acute epigastric pain, nausea, and bilious vomiting. EGD revealed retained food in the stomach and what appeared to be a large, approximately 2-cm obstructing gallstone in the duodenal bulb (Figure 1). After multiple instruments failed to retrieve the gallstone, a needle knife was utilized to break the gallstone into pieces that were then retrieved using a Roth net. After removal of the gallstone, a suspected cholecystoduodenal fistula was seen. An emergent computed tomography of the abdomen confirmed a fistulous tract between the gallbladder and duodenum (Figure 2). Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated contrast extravasating from the gallbladder into the duodenum. Biliary sphincterotomy was performed with the placement of a 10 Fr x 5 cm plastic biliary stent in the common bile duct. An additional stone that was impacted within the cholecystoduodenal fistula was removed successfully using a stone-extracting balloon (Figure 3). An endoscopic suturing device was utilized to place one endoscopic suture, resulting in complete closure of the fistula (Figure 4). The patient subsequently underwent uncomplicated, open cholecystectomy with no fistula seen during surgery.