Saikiran Raghavapuram

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.

Ectopic Hepatocellular Carcinoma within a Choledochal Cyst Diagnosed Using Single-Operator Digital Cholangioscopy

Ectopic Hepatocellular Carcinoma within a Choledochal Cyst Diagnosed Using Single-Operator Digital Cholangioscopy

Verrucous carcinoma of the esophagus—remains a diagnostic enigma

with no prominent cytological atypia and typical vascular invasion are shown in Fig. 3 (hematoxylin and eosin, magnification ×20 and ×40, respectively). The polyp stalk was free of tumor infiltration. A strict endoscopic and radiological surveillance program was undertaken, based on upper endoscopy and contrast-enhanced CT scan performed at month 3 and 6 after polypectomy. No evidence of recurrent HCC was reported after one year, including also a positive emission computed tomography. Fatigue and anemia progressively improved after endoscopic polyp resection, with return to normal hemoglobin levels within six months. HCC extension to small bowel is considered anecdotal and generally restricted to patients with diffuse neoplastic involvement of the liver [1, 2]. To our knowledge, only one case has been described of a single duodenal isolated recurrence of HCC [2]. However, this patient was not a liver transplant recipient and had fibrolamellar HCC. HCC recurrence nowadays is reported at a rate lower than 20% after liver transplantation, according to a retrospective radiologic study involving 119 patients [3]. Notably, in the latter study extra-hepatic recurrence of HCC without liver involvement was not a rare event, being observed in 4 of 16 recurrent cases. To our knowledge, this is the first report of a duodenal recurrence of a solitary HCC after liver transplantation. Although this unusual site of extrahepatic tumor recurrence is probably rare, this possibility, together with other more frequent classical sites, such as lymph nodes, lung and adrenal glands, should be taken into consideration in the long-term surveillance of patients liver-transplanted for HCC.

Mushroom Poisoning Mimicking Painless Progressive Jaundice: A Case Report with Review of the Literature

Mushroom poisoning is common in the United States. The severity of mushroom poisoning may vary, depending on the geographic location, the amount of toxin delivered, and the genetic characteristics of the mushroom. Though they could have varied presentation, early identification with careful history could be helpful in triage. We present a case of a 69-year-old female of false morel mushroom poisoning leading to hepatotoxicity with painless jaundice and biochemical pancreatitis.

Pure Squamous Cell Carcinoma of the Gallbladder Masquerading as a Hepatic Mass

Gallbladder (GB) carcinomas are adenocarcinomas (AC) in the majority of cases. Adenosquamous carcinoma (ASC) and pure squamous cell carcinoma (SCC) of the gallbladder are rarely encountered and comprise 1-3% of gallbladder cancer cases. Pure squamous cell carcinoma of the gallbladder is rarer with less than 1% of the incidence. Most of the published literature is based on case reports and case series. The survival rates of ASC and SCC of the gallbladder are significantly lower (mean of five months) compared to the AC of the gallbladder (mean survival of 11.4 months). Most of these lesions are advanced at presentation, rendering them unresectable and resulting in a poor prognosis. However, if the lesions are diagnosed at an early stage, they could potentially be resectable. We report one such rare case of pure SCC GB presenting as a hepatic mass. The patient subsequently underwent resection of the gallbladder and liver mass with complete recovery and is currently planned for chemotherapy and radiation treatment.

Downhill esophageal varices: unusual cause of hematemesis

“Downhill” esophageal varices distributed predominantly in the proximal esophagus are unusual causes of hematemesis, comprising 0.1% of all cases of variceal hemorrhage. They are seen in up to 30% of cases of superior vena cava (SVC) obstruction from benign and malignant causes. The pathophysiology of their formation and management is different from that of the more usual “uphill” varices commonly seen that result from portal hypertension. These varices are caused by the formation of collaterals caused by obstruction of the superior vena cava. Their distribution in the esophagus varies relative to the level of SVC obstruction with the azygos vein. Patients with end-stage renal disease (ESRD) who are receiving long-term dialysis are particularly at risk for SVC obstruction/stenosis from the sustained use of indwelling

Linitis plastica: a harbinger of an unusual cause of gastric wall thickening

1 Metastasis to the GI tract is uncommon, but when it occurs, the stomach is the most common site. The most common primary cancers that metastasize to the stomach include breast and renal cell carcinoma. Among breast cancers, invasive lobular cancer is known to metastasize more often to the stomach than does invasive ductal cancer. The clinical presentation of such a metastasis is very nonspecific. The endoscopic presentation is heterogeneous as well, with solitary and submucosal lesions being the most

Metastatic duodenal germ cell tumor diagnosed with endoscopic ultrasound

Testicular tumors are the most common solid tumors reported in young males aged 15–35 years [1, 2]. These tumors frequently metastasize to retroperitoneal lymph nodes, but only 5% of these tumors seed the gastrointestinal (GI) tract [3, 4], with the duodenum being the least common site (1.4%) [4]. Local extension from the retroperitoneal lymph node into the GI tract is the common method of spread. We report on a 44-year-old man with symptoms of gastric outlet obstruction. Computed tomography (CT) of the abdomen showed a bilobed retroperitoneal mass of 7×5 cm compressing the duodenum, suspicious for duplication cyst (▶Fig. 1a, b). Esophagogastroduodenoscopy showed a subepithelial nearobstructive mass in the second portion of the duodenum, which appeared cystic on palpation with closed forceps (▶Fig. 1 c). Endoscopic ultrasound (EUS) showed a 7×5.4 cm solid cystic mass (▶Fig. 1d). Fine-needle biopsy (FNB) with a 22-gauge needle (▶Fig. 1 e) revealed poorly differentiated epithelioid carcinoma, with unknown primary. Given the patient’s age, testicular tumor was a highly likely differential diagnosis. The patient underwent pancreas-sparing duodenal resection. Histology showed a mixed germ cell tumor with unusual presence of cartilage (▶Fig. 1 f). Ultrasound of the testes showed a 1.7 cm E-Videos

Endoscopic Dissolution of Gastric Lipoma with Argon Plasma Coagulation

A 47-year-old patient presented from outside the hospital for evaluation of iron deficiency anemia (IDA). The endoscopic workup suggested a gastric antral subepithelial lesion with an overlying arteriovenous malformation (AVM). Endoscopic ultrasound (EUS) revealed the lesion to be a lipoma. Given the patient’s anemia and blood transfusion requirements, the AVM was treated with argon plasma coagulation (APC). During this treatment, desiccation of fat was noted with a significant decrease in the size of the subepithelial lesion (the gastric lipoma). While the APC therapy was intended for management of the overlying AVM, it resulted in the partial dissolution of the gastric lipoma, proving to be a potential diagnostic and therapeutic tool.

Widefield Endoscopic Mucosal Resection for Treatment of Proximal Esophageal Leukoplakia

Q1 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 Afor the management of new onset dysphagia to solids. She had a history of oropharyngeal leukoplakia, which was being followed by ear, nose, and throat doctor. She had several medical comorbidities including ischemic heart disease with automatic implantable cardioverter-defibrillator. She denied any tobacco or alcohol use. Esophagogastroduodenoscopy showed narrowing of the proximal esophagus with characteristic white plaques suggestive of esophageal leukoplakia (Figure A). Biopsy showed squamous cell carcinoma in situ (Figure B, arrows). Endoscopic ultrasound revealed the lesion to be mucosal (T1aN0). Endoscopic mucosal resection was performed, resulting in the successful removal of the lesion (Figure C). She was discharged on proton pump inhibitor and steroids to minimize stricture