Mel A. Ona

Hemostatic powder spray: a new method for managing gastrointestinal bleeding

Gastrointestinal bleeding is a leading cause of morbidity and mortality in the United States. The management of gastrointestinal bleeding is often challenging, depending on its location and severity. To date, widely accepted hemostatic treatment options include injection of epinephrine and tissue adhesives such as cyanoacrylate, ablative therapy with contact modalities such as thermal coagulation with heater probe and bipolar hemostatic forceps, noncontact modalities such as photodynamic therapy and argon plasma coagulation, and mechanical hemostasis with band ligation, endoscopic hemoclips, and over-the-scope clips. These approaches, albeit effective in achieving hemostasis, are associated with a 5–10% rebleeding risk. New simple, effective, universal, and safe methods are needed to address some of the challenges posed by the current endoscopic hemostatic techniques. The use of a novel hemostatic powder spray appears to be effective and safe in controlling upper and lower gastrointestinal bleeding. Although initial reports of hemostatic powder spray as an innovative approach to manage gastrointestinal bleeding are promising, further studies are needed to support and confirm its efficacy and safety. The aim of this study was to evaluate the technical feasibility, clinical efficacy, and safety of hemostatic powder spray (Hemospray, Cook Medical, Winston-Salem, North Carolina, USA) as a new method for managing gastrointestinal bleeding. In this review article, we performed an extensive literature search summarizing case reports and case series of Hemospray for the management of gastrointestinal bleeding. Indications, features, technique, deployment, success rate, complications, and limitations are discussed. The combined technical and clinical success rate of Hemospray was 88.5% (207/234) among the human subjects and 81.8% (9/11) among the porcine models studied. Rebleeding occurred within 72 hours post-treatment in 38 patients (38/234; 16.2%) and in three porcine models (3/11; 27.3%). No procedure-related adverse events were associated with the use of Hemospray. Hemospray appears to be a safe and effective approach in the management of gastrointestinal bleeding.

Acute Hepatitis after Ingestion of a Preparation of Chinese Skullcap and Black Catechu for Joint Pain.

Many herbal preparations are routinely used and have been occasionally associated with a wide range of side effects, from mild to severe. Chinese skullcap and black catechu are herbal medications commonly used for their hepatoprotective and other properties. We report a case of acute toxic hepatitis associated with ingestion of Chinese skullcap and black catechu in one preparation for the alleviation of joint pain.

Self-Expanding Metal Stent (SEMS): an innovative rescue therapy for refractory acute variceal bleeding

Background: Acute variceal bleeding (AVB) is a life-threatening complication of liver cirrhosis or less commonly splenic vein thrombosis. Pharmacological and endoscopic interventions are cornerstones in the management of variceal bleeding but may fail in 10 – 15 % of patients. Rescue therapy with balloon tamponade (BT) or transjugular intrahepatic portosystemic shunt (TIPS) may be required to control refractory acute variceal bleeding effectively but with some limitations. The self-expanding metal stent (SEMS) is a covered, removable tool that can be deployed in the lower esophagus under endoscopic guidance as a rescue therapy to achieve hemostasis for refractory AVB. Aims: To evaluate the technical feasibility, efficacy, and safety of SEMS as a rescue therapy for AVB. Methods: In this review article, we have performed an extensive literature search summarizing case reports and case series describing SEMS as a rescue therapy for AVB. Indications, features, technique, deployment, success rate, limitations, and complications are discussed. Results: At present, 103 cases have been described in the literature. Studies have reported 97.08 % technical success rates in deployment of SEMS. Most of the stents were intact for 4 – 14 days with no major complications reported. Stent extraction had a success rate of 100 %. Successful hemostasis was achieved in 96 % of cases with only 3.12 % found to have rebleeding after placement of SEMS. Stent migration, which was the most common complication, was observed in 21 % of patients. Conclusion: SEMS is a safe and effective alternative approach as a rescue therapy for refractory AVB.

Acute Liver Toxicity due to Efavirenz/Emtricitabine/Tenofovir

The fixed-dose combination of Efavirenz/Emtricitabine/Tenofovir is a first-line agent for the treatment of HIV; however few cases have reported hepatotoxicity associated with the drug. We report a case of Efavirenz/Emtricitabine/Tenofovir-associated hepatotoxicity presenting mainly with hepatocellular injury characterized by extremely elevated aminotransferase levels, which resolved without acute liver failure or need for liver transplant referral.

Acute liver function decompensation in a patient with sickle cell disease managed with exchange transfusion and endoscopic retrograde cholangiography

Sickle cell intrahepatic cholestasis is a relatively uncommon complication of homozygous sickle cell anemia, which may lead to acute hepatic failure and death. Treatment is mainly supportive, but exchange transfusion is used as salvage therapy in life threatening situations. We describe a case of a 16-year-old female with homozygous sickle cell anemia who presented to the emergency room with fatigue, malaise, dark urine, lower back pain, scleral icterus and jaundice. She was found to have marked hyperbilirubinemia, which persisted after exchange transfusion. Because of the concomitant presence of gallstones and choledocholithiasis, the patient underwent endoscopic ultrasound and laparoscopic cholecystectomy followed by endoscopic retrograde cholangiography and sphincterotomy.

Characteristics and Risk Stratification of Colon Polyps among Asymptomatic Hispanic Patients Undergoing First Time Screening Colonoscopy: A Retrospective Study

Goals: To determine characteristics of polyps in Hispanic patients undergoing first-time screening colonoscopy and to risk stratify them based on findings. Background: Current guidelines recommend screening colonoscopy beginning at age 50 in the average-risk population. Race has been shown to influence the risk of colorectal cancer, thus leading to the recommendation of initiating screening in blacks at the age of 45. Few data exist on the prevalence and characteristics of colon polyps among U.S. Hispanics. Study: Retrospective study at a community hospital in Brooklyn, NY serving large Hispanic population including patients >50 undergoing first-time screening colonoscopy who met inclusion and exclusion criteria. Results: Our final data analysis of 192 Hispanic patients showed that the majority of polyps (56%) were tubular adenomas with 17% showing dysplastic features. In a risk stratification analysis, 52.6% of patients fell into the low risk category while 47.4% of patients had adenomas with at least one high risk feature for progression to colon cancer. Conclusions: We found that Hispanic patients undergoing first-time screening colonoscopy have increased risk for malignancy based on the features of their polyps. There is need for further, race-specific studies determining the cause of increased progression to neoplasia and the possible need for earlier screening.

Atypical Presentation of Gastric Volvulus

Gastric volvulus has been reported in all age groups; however, it is typically diagnosed in the elderly. Organo-axial volvulus is the most common type, followed by the mesentero-axial and the combined types. Depending on the etiology, gastric volvulus can also be classified as primary (idiopathic) or secondary. Treatment of acute gastric volvulus involves laparoscopic or endoscopic procedures/maneuvers, depending on the severity of symptoms and surgical eligibility of the patient. Chronic gastric volvulus is typically managed conservatively, although laparoscopic or endoscopic interventions can also be employed depending on the severity of presentation.

Endocuff-Assisted Colonoscopy-A Novel Accessory in Improving Adenoma Detection Rate: A Review of the Literature.

Endocuff (Arc Medical Design) is a U.S. Food and Drug Administration-approved device that is attached like a cap to the distal tip of the colonoscope; it is used to improve adenoma detection rates during colonoscopy. The aim of this review was to summarize and evaluate the clinical and technical efficacy of Endocuff in improving adenoma detection rate. A comprehensive literature review was performed to identify studies describing this technique. In this review article, we have summarized case series and reports describing Endocuff use and results. The reported indications, results, limitations, and complications are discussed.

Through-the-scope endoscopic balloon dilatation of a nonsteroidal anti-inflammatory drug-induced diaphragm-like colonic stricture

A 56-year-old woman with a history of sciatica, who had been taking nonsteroidal anti-inflammatory drugs (NSAIDs) for one year complained of abdominal fullness, rectal bleeding, and decreased stool caliber for the past six months. An endoscope could not be extended beyond a stenosed region within the descending colon. This narrowed area appeared suggestive of a diaphragm-like stricture and was surrounded by areas of healed colitis and fibrosis (Fig. 1). Biopsies revealed lamina propria fibrosis with eosinophilic infiltration (Fig. 1). A through-the-scope sequential balloon dilator (Fig. 2) was used to dilate the stricture (Fig. 2) and an endoscope was subsequently advanced into the cecum, which revealed no further colopathy. The patient tolerated the procedure well; she was advised to avoid NSAIDs, and upon follow up she reported resolution of her symptoms. Colonic diaphragm-like stricture disease was first reported in 1989. An estimated 50 cases have been described in the last 10 years. Most cases were linked to long-term use of NSAIDs [1,2]. The pathophysiology of NSAID-induced colonic strictures is still not clear, but some studies attribute fibrosis to local toxic effects of NSAID preparations on mucosal integrity due to inhibition of protective prostaglandins [3]. Colonic diaphragm-like strictures should be considered in the

Endoscopic and imaging appearance after injection of an ano-rectal bulking agent.

The use of hyaluronic acid and dextranomer (Solesta, Salix) injection in the anal canal is an emerging modality in the treatment of fecal incontinence. However, little is known regarding the endoscopic and radiological appearance following injection of this ano-rectal bulking agent. We report computed tomography and endoscopic findings after hyaluronic acid/dextranomer injection in the ano-rectal area.