Sajan Jiv Singh Nagpal

Gastric Polyposis: A Rare Cause of Iron Deficiency Anemia in a Patient With Portal Hypertension.

Portal hypertension leading to gastric polyposis has rarely been reported. More common gastric manifestations of portal hypertension are portal hypertensive gastropathy and gastric antral vascular ectasia (GAVE). We report a case of a patient in whom portal hypertension manifested as bleeding gastric polyps leading to transfusion-dependent iron deficiency anemia.

Successful Curative Resection of Early Gastric Cancer by Endoscopic Submucosal Dissection in a High-Risk Cirrhotic Patient

Endoscopic submucosal dissection (ESD) technique was developed in the 1990s for the treatment of early gastric cancer (EGC) [1]. ESD enables en bloc resection, provides adequate histopathological staging and long-term cure rates similar to surgery with lower morbidity, and is considered superior to the piecemeal endoscopic mucosal resection (EMR) technique. However, due to the lower prevalence of gastric cancer and the absence of a universal endoscopic screening program in the USA, cases of EGC are extremely rare [2]. We report a case of EGC in a high-risk surgical patient successfully treated with ESD.

Gastric Perforation Caused by a Left Ventricular Assist Device.

A 52-year-old man with a history of necrotizing pancreatitis complicated by walled-off necrosis requiring cystogastrostomy drainage five years previously was referred for evaluation of subacute malnourishment, early satiety, and abdominal pain. Computed tomography of the abdomen and endoscopic ultrasound showed a mature, 13-cm walled-off complex collection in the region of the pancreatic body (a). Initially, given the history and available imaging, there was no suspicion of malignancy, and the collection was drained by cystogastrostomy with deployment of a lumen-apposing metal stent. Thick, mucinous drainage was expressed (b) without overt release of necrotic or thin liquid content. Subsequent identification of suspicious hepatic lesions—thought initially to be abscesses—prompted percutaneous biopsy confirming metastatic pancreatic adenocarcinoma. At follow-up drainage two weeks later, the patient noted decreased pain and improved oral tolerance. Interval transcystogastrostomy endoscopic imaging demonstrated retained thick mucinous material that when suctioned revealed an adenomatous patterned wall with a central solid component consistent with primary mucinous adenocarcinoma (c). (Informed consent was obtained from the patient to publish these images.)

Online Images in the Medical SciencesPalmomental Reflex

CASE SUMMARY A 67-year-old woman with no known dementia was admitted from a nursing facility for a 3-day history of increasing somnolence. Medication review revealed high doses of diazepam, gabapentin and duloxetine. A thorough physical examination revealed a positive palmomental reflex. As shown in the Supplemental Digital Content 1 (see Video, http://links.lww.com/ MAJ/A67), the reflex is elicited by briskly stroking the palm from proximal to distal along the thenar eminence. A twitch of the ipsilateral chin is observed through contraction of the mentalis muscle. Infection was ruled out by a complete septic workup, including chest x-ray, urinalysis and aerobic/anaerobic blood cultures. MRI of the brain showed global volume loss and microvascular changes. The offending medications were discontinued, and supportive care was initiated. Over the course of 3 days, her mental status improved; however, the reflex persisted. The palmomental reflex is a primitive reflex similar to the Babinski’s reflex and is representative of impairment of cortical inhibitory pathways as seen in other frontal release signs. Primitive reflexes are commonly present in infancy and disappear as the frontal lobe matures during development. As a person ages, disruption in cortical inhibitory pathways causes the reappearance of primitive reflexes. Therefore, it may be observed in both localized and diffuse neurological conditions, such as Alzheimer’s disease, or other forms of dementia, but may also be present in elderly populations without cognitive impairment.

Technique for Retrieving Basket and Lithotripter During Endoscopic Retrograde Cholangiopancreatography

27-year-old woman with a prior cholecystectomy Aunderwent endoscopic retrograde cholangio pancreatography (ERCP) for abdominal pain and choledocholithiasis. After biliary sphincterotomy, a flower basket was used to grasp and retrieve a 15-mm mid– common bile duct (CBD) stone. However, the flower basket became impacted in the CBD (Figure A). Then, the distal CBD was dilated using a 15-mm CRE balloon dilator (Boston Scientific, Natick, MA). Despite this, the basket could not be pulled out. The outer plastic sheath of the basket was removed and a Soehendra mechanical lithotripter then was inserted alongside the basket wires into the CBD and mechanical lithotripsy (Cook Medical, Winston-Salem, NC) of the stone was attempted. The lithotripter also became impacted in the CBD over the basket (Figure B) and could not be pulled out. The presence of the impacted basket, lithotripter, and wires in the CBD precluded placement of a stent, but there was good bile drainage seen. Because of the prolonged efforts and complexity, it was elected to terminate the procedure. The basket and lithotripter wires were cut and secured at the patient’s mouth with an adhesive tape. The patient was placed on a liquid diet along with broad-spectrum antibiotics for prophylaxis against cholangitis. ERCP was repeated after 3 days and attempts to drag the impacted devices and stone with an extraction balloon were unsuccessful. Electrohydraulic lithotripsy (EHL) then was performed using Spyglass (Boston Scientific) and the stone was fragmented. The impacted basket and lithotripter could be pulled out of the bile duct by using a rat-tooth forceps, passed under endoscopic and fluoroscopic guidance (Figure C). An extraction balloon was swept to clear the residual stone fragments. A 10F 10-cm plastic stent was inserted temporarily for 4 weeks to ensure biliary drainage and the patient did well.