Rayburn Rego

Management of gastric variceal bleeding: Role of endoscopy and endoscopic ultrasound

Gastric varices (GVs) are notorious to bleed massively and often difficult to manage with conventional techniques. This mini-review addresses endoscopic management principles for gastric variceal bleeding, including limitations of ligation and sclerotherapy and merits of endoscopic variceal obliteration. The article also discusses how emerging use of endoscopic ultrasound provides optimism of better diagnosis, improved classification, innovative management strategies and confirmatory tool for eradication of GVs.

Intrapancreatic Accessory Spleen: Investigative Dilemmas and Role of EUS-Guided FNA for Diagnostic Confirmation

CONTEXT We submit a case of intrapancreatic accessory spleen. CASE REPORT A 33-year-old patient with history of dyspepsia underwent imaging studies suggestive of a neuroendocrine tumor. After referral to our institute, endoscopic ultrasound guided fine needle aspiration (EUS-FNA) confirmed diagnosis as intrapancreatic accessory spleen. DISCUSSION An accessory spleen may develop from estranged mesenchymal cells due to fusion failure of the splenic anlage. The prevalence of an accessory spleen is 10-30% with 80% of them present at the splenic hilum and 17% in the pancreatic tail. Intrapancreatic accessory spleen is commonly misdiagnosed as a pancreatic tumor. Since, the differential diagnosis includes pancreatic neuroendocrine tumors, additional investigation with EUS-FNA should be considered when radiological diagnosis is not definitive. CONCLUSION For diagnosis of intrapancreatic accessory spleen, radiographic imaging is useful, but lacks specificity without tissue diagnosis. Diagnosis can be safely and reliably established with EUS-FNA, leading to a benign prognosis and avoidance of unnecessary surgical intervention.

Extensive Extramedullary Disease Involving the Colon in Multiple Myeloma: A Case Report and Review of Literature

IntroductionOrgan involvement in multiple myeloma (MM) is characterized by infiltrative disease or by a myelomatous mass known as a plasmacytoma. We present a patient with MM who had extensive extramedullary involvement of the colon and a review of the literature on colon plasmacytomas.Case reportA 57-year-old male with MM presented with disease relapse in 2007, workup showing biopsy confirmed left perinephric extra-medullary disease involving the adjacent colon. Positron emission-tomography (PET) exhibited intense pan-colonic fluoro-deoxyglucose (FDG) uptake and computed-tomography confirmed extensive infiltrating soft tissue thickening in the ascending, transverse, and descending colon representing plasmacytomas. The patient underwent an autologous hematopoietic stem cell transplantation after conditioning with high-dose melphalan. Restaging PET-scan showed complete resolution of colonic extra-medullary plasmacytomas. Extramedullary plasmacytomas (EMP) are rare and constitute 4% of all plasma cell tumors.Discussion and ConclusionColonic plasmacytoma is an extremely rare site, with fewer than 25 cases reported in the literature. Colonic plasmacytomas have different presentations depending on the size and location. Treatment options for primary EMPs include surgical resection, radiotherapy, and chemotherapy. The primary treatment option for secondary EMP is systemic chemotherapy. This rare pan-colonic plasmacytoma, as a part of extramedullary myeloma, showed an impressive response to chemotherapy.

Isolated gastric crystal-storing histiocytosis: a rare marker of occult lymphoproliferative disorders

Rare incidental endoscopic findings may have grave implications requiring a high index of suspicion with a low threshold for histopathological examination. We present a case of just such an incidental gastric lesion, which on histopathological analysis was determined to be Crystal-Storing Histiocytosis (CSH), a rare manifestation of lymphoproliferative disorders. An elderly patient presented for an upper gastrointestinal endoscopy with longstanding symptoms suggestive of gastroesophageal acid reflux despite proton pump inhibitor use. The upper endoscopy reported a normal oesophagus and duodenum. However, a questionable submucosal lesion was noted in the antrum. This resulted in a referral to our centre for an endoscopic ultrasound (EUS). While performing the EUS, a 2 cm whitish patch was incidentally noted on the greater curvature of the …

PSEUDOMELANOSIS DUODENI: A RARE FINDING FROM UPPER ENDOSCOPY

Dear Editor, A 65-year-old black woman with a history of end-stage renal disease (requiring hemodialysis), diabetes mellitus and hypertension, underwent endoscopy for work-up of anemia. Upper endoscopy revealed an abnormal dark pigmentation in the duodenal bulb and the second portion of the duodenum. Biopsies of the duodenum revealed a black granular pigment within the tips of villi. The diagnosis of pseudomelanosis duodeni was made on the basis of clinical, endoscopic and histological findings. Pseduomelanosis duodeni is an extremely rare condition not associated with a duodenal malignancy. To an endoscopist, the typical finding is a flat hyperpigmented brownish-black speckled duodenal mucosa. Histology demonstrates the accumulation of a dark pigment within the macrophages of the lamina propria. There are no cases where endoscopic hyperpigmentation was not supported by histological evidence of pseudomelanosis duodeni. The present case is being submitted for its classical endoscopy and histological findings. A 65-year-old black woman with a history of end-stage renal disease (requiring hemodialysis), diabetes mellitus, hypertension, and hypothyroidism was referred to our clinic for anemia. The patient was on multiple medications, including zolpidem, aspirin, clonidine, hydralazine, insulin, levothyroxine, and metoprolol. Upper endoscopy revealed an abnormal dark pigmentation in the duodenal bulb and the second portion of the duodenum (Fig. 1). Biopsies of the duodenum were taken, and histology revealed a black granular pigment within the tips of villi, which was negative for iron (Fig. 2). The diagnosis of pseudomelanosis duodeni was made on the basis of clinical, endoscopic and histological findings. Pseduomelanosis duodeni is an extremely rare, benign condition first described by Bisordi and Kleinman in 1976. To an endoscopist, the typical finding is a flat hyperpigmented brownish-black speckled duodenal mucosa. Histology unequivocally demonstrates the accumulation of a dark pigment within the macrophages of the lamina propria.There are no cases where endoscopic hyperpigmentation was not supported by histological evidence of pseudomelanosis duodeni; however, there are cases in which biopsies of a normal-appearing duodenum have disclosed pseudomelanosis duodeni histologically. Review of the literature shows that pseudomelanosis duodeni usually occurs in women older than 60 years of age and rarely occurs in a setting other than chronic renal failure, arterial hypertension, and/or diabetes mellitus. Consequently, certain medications (e.g. ferrous sulfate, hydralazine, propanolol, hydrochlorothiazide, furosemide) have been associated with this condition. The brownish-black pigment is mainly ferrous sulfide with small amounts of other elements. The source and pathogenesis of pigment deposition exclusively in the duodenal mucosa and the prognostic implications of pseudomelanosis duodeni are unknown. There has been no documented fibrosis, duodenitis, stricture formation or ulceration described in the literature. Hence, the significance of such finding, prognosis, and guidelines regarding endoscopic surveillance have not been determined.

Malt Lymphoma of the Colon: a Rare Occurrence

Non-Hodgkins lymphoma (NHL) is one of the leading causes of cancer in the US. NHL can be seen in the gastrointestinal tract in extralymphatic presentation. Primary GI lymphomas are rare. When present, they are more common in the stomach and small bowel. The most common histologic subtype affecting the gastrointestinal tract and colon is diffuse large B cell lymphoma. These are generally aggressive and are composed of rapidly proliferating cells of B cell origin. The second most common colorectal lymphoma is mucosa-associated lymphoid tissue (MALT)-associated low-grade B cell lymphoma. MALT-associated lymphomas are low-grade tumors arising from B cells associated with mucosal immunity. MALT is predominantly found in the gastrointestinal tract and plays a vital role in immune surveillance, mucosal regeneration, and in carcinogenesis. In the colon, lymphoid tissue consists of isolated lymphoid follicles which are composed mainly of B lymphocytes. These cells occasionally undergo abnormal proliferation and give rise to lymphoma of the MALT type. Colonic MALT lymphoma is a rare entity of increasing recognition, for which no definitive treatment has been established. There are very few case reports of colonic MALT type lymphoma given its uncommon occurrence, thereby lacking sufficient data required in evaluation, management, and treatment of these patients. We describe a rare case of colon marginal-zone B cell lymphoma of MALT (MALT lymphoma) found on routine colonoscopy. Case Presentation

Use of a convex probe-endobronchial US endoscope in EUS of the rectum and FNA

between the PS and SEMS groups, missing response occurred in patients who died before the first appointment, and they were assigned to unsuccessful drainage in the analysis. Finally, in this study, we focused on the efficacy of SEMS and PS in unresectable hilar cholangiocarcinoma; thus, the patients in both groups did not receive any treatment modalities that affected patient survival such as chemotherapy, brachytherapy, and external beam radiation.

Surviving Primary Pancreatic Squamous Cell Carcinoma: A Rare Entity.

Primary squamous cell carcinoma (SCC) is a rare malignancy with a poor prognosis, reported in the literature predominantly as case reports [1–3]. This is primarily due to the fact that the pancreas is devoid of any squamous cells. Therefore, a thorough search for a primary tumor elsewhere is needed before establishing the diagnosis. Management options include surgical resection with adjuvant chemotherapy or concomitant chemo and radiotherapy where surgery is not feasible. However, the outcomes in these patients, irrespective of the treatment modality, have been anecdotally poor with little known about the natural history following treatment.

An intriguing cause of intractable nausea and vomiting

DOI: 10.4103/1319-3767.114510 A 60‐year‐old lady with history of reflux disease and breast cancer status post‐lumpectomy and lymph node dissection followed by chemotherapy and now in remission, was admitted with progressively increasing nausea and vomiting of 2 months duration. She also described episodic epigastric abdominal pain, which increased on food intake and led to vomiting, which brought her instant relief. She had lost about 80 lbs of weight during her chemotherapy, which stabilized for few months but was now again falling because of her inability to eat. There was no alteration in bowel habits, fever or any other associated symptoms. She had two previous admissions for similar problems at a local hospital where symptomatic relief was achieved with dobhoff tube placement. She had been tolerating the tube feeds well, however, for last 2 days her symptoms reappeared raising concern of obstructed dobhoff and hence a gastroenterologist was consulted for endoscopic evaluation. Her blood‐work was normal. Barium swallow showed extrinsic compression of the 3rd portion of duodenum, at the level of superior mesenteric artery (SMA) crossing, causing partial obstruction as barium passes through the 3rd to 4th portion [Figure 1]. Computed tomography (CT) scan was obtained which was diagnostic [Figure 2]. Esophagogastroduodenoscopy revealed a patent 3rd part of duodenum.

Endoscopic removal of migrated vascular embolic material from the common bile duct: multi-modality approach (with video).

A 74-year-old man underwent a percutaneous transhepatic cholangiography (PTC) for a non-malignant common bile duct (CBD) stricture with drain placement. At a subsequent drain exchange, he developed significant gastrointestinal bleeding, necessitating coil embolization of the hepatic artery (HA). He did well afterwards and the drains were removed. Three years later, he developed cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) done at an outside facility revealed a foreign body, assumed to be a jagwire from prior ERCP. He was referred to us for further management. A computed tomography (CT) scan noted hardware within the porta-hepatis that caused streak artifact, along with dilation of intrahepatic bile ducts. Review of the case suggested endovascular coils that had eroded into the CBD from HA (Fig. 1) and ERCP was planned. Due to concern about HA rupture during retrieval, a catheter was positioned in the HA by interventional radiology (IR) to facilitate rapid re-embolization, should uncontrolled bleeding occur (Fig. 1). During ERCP, balloon extraction of a vascular plug was carried out, followed by removal of filamentous wires using rat-tooth forceps (Fig. 2). The duct was then accessed with spyglass to extract the more proximal wires using SpyBite® biopsy forceps (Boston Scientific, Natick, MA, USA) (Fig. 2). Fluoroscopic video obtained at the end of the procedure demonstrated a thin sliver of embolic material remaining in the CBD that would probably epithelialize. Post-cholecystectomy clips, suture material and displaced stents are commonly discussed foreign bodies in the CBD. There are limited reports on migration of vascular embolic material into the duodenum; however, erosion of vascular coils into the CBD is an extremely rare situation. The present case demonstrates successful use of various endoscopic techniques to manage this otherwise high-risk and presumably surgical condition. Adopting a multi-modality approach with IR backup may prevent the need for surgical exploration of the CBD in such intricate cases. Our method of management may serve as a teaching tool for endoscopists who may encounter a similar situation.