Tagore Sunkara

Perioperative Management of Direct Oral Anticoagulants (DOACs): A Systemic Review

Direct oral anticoagulants (DOACs) are in wide use among patients requiring both short- and long-term anticoagulation, mainly due to their ease of use and the lack of monitoring requirements. With growing use of DOACs, it is imperative that physicians be able to manage patients on these medications, especially in the perioperative period. We aim to provide guidance on the management of DOACs in the perioperative period. In this review, we performed an extensive literature search summarizing the management of patients on direct-acting anticoagulants in the perioperative period. A total of four direct-acting oral anticoagulants were considered appropriate for inclusion in this review. The drugs were dabigatran etexilate mesylate (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), and edoxaban (Savaysa). Management of patients on DOACs in the perioperative period involves an assessment of thromboembolic event risk while off anticoagulation compared to the relative risk of bleeding if such drug is continued. DOACs may not need to be discontinued in minor surgeries or procedures, and in major surgeries, they may be discontinued hours prior depending on drug pharmacokinetics and renal function of the patients.

Imaging of gall bladder by endoscopic ultrasound

Endoscopic ultrasonography (EUS) is considered a superior investigation when compared to conventional ultrasonography for imaging gall bladder (GB) lesions as it can provide high-resolution images of small lesions with higher ultrasound frequencies. Examination of GB is frequently the primary indication of EUS imaging. Imaging during EUS may not remain restricted to one station and multi-station imaging may provide useful information. This review describes the techniques of imaging of GB by linear EUS from three different stations. The basic difference of imaging between the three stations is that effective imaging from station 1 is done above the neck of GB, from station 2 at the level of the neck of GB and from station 3 below the level of the neck of GB.

Gastric schwannoma—a rare benign mimic of gastrointestinal stromal tumor

Abstract Schwannomas most commonly manifest as acoustic neuromas in the vestibulo-cochlear nerve (CN VIII). These may occur unilaterally as primary tumors, or bilaterally secondary to neurofibromatosis type 2. More rarely, they present in extra-cranial sites, including the gastrointestinal tract. Gastrointestinal schwannomas are believed to arise from Auerbach’s plexus in the muscularis propria, and are classified as mesenchymal tumors. Here, we report a rare case of a 49-year-old woman who had surgical resection of a gastric mass which was eventually diagnosed as gastric schwannoma.

Role of endoscopic ultrasound in idiopathic pancreatitis

Recurrent acute pancreatitis (RAP) is defined based on the occurrence of two or more episodes of acute pancreatitis. The initial evaluation fails to detect the cause of RAP in 10%-30% of patients, whose condition is classified as idiopathic RAP (IRAP). Idiopathic acute pancreatitis (IAP) is a diagnostic challenge for gastroenterologists. In view of associated morbidity and mortality, it is important to determine the aetiology of pancreatitis to provide early treatment and prevent recurrence. Endoscopic ultrasound (EUS) is an investigation of choice for imaging of pancreas and biliary tract. In view of high diagnostic accuracy and safety of EUS, a EUS based management strategy appears to be a reasonable approach for evaluation of patients with a single/recurrent idiopathic pancreatitis. The most common diagnoses by EUS in IAP is biliary tract disease. The present review aims to discuss the role of EUS in the clinical management and diagnosis of patients with IAP. It elaborates the diagnostic approach to IAP in relation to EUS and other different modalities. Controversial issues in IAP like when to perform EUS, whether to perform after first episode or recurrent episodes, comparison among different investigations and the latest evidence significance are detailed.

Acute duodenal intramural hematoma complicated by acute pancreatitis—a rare complication of endoscopic epinephrine injection therapy

Abstract Intramural duodenal hematoma (IDH) is a rare complication in endoscopic management of ulcer hemorrhage. Usually noted in cases of blunt abdominal trauma, non-traumatic IDHs have been reported in individuals on anticoagulation, with blood disorders, pancreatic diseases and in endoscopic procedures such as biopsy, sclerotherapy and argon plasma coagulation. Patients may be asymptomatic or present with acute blood loss anemia, abdominal pain or vomiting. We report a case of an 83-year-old man with melena and syncope who underwent endoscopy for bleeding ulcer control and subsequently developed acute pancreatitis due to an acute IDH. Computed tomography (CT) scan confirms the diagnosis. Most cases are conservatively managed however when unsuccessful, laparoscopic surgical drainage or ultrasound or CT guided drainage can be performed.

A Case of Concurrent Gastric and Pancreatic Plasmacytomas in a Patient With Multiple Myeloma: An Extremely Rare Entity

Multiple myeloma (MM), a plasma cell tumor, is primarily a disease of the bone marrow. Extramedullary plasmacytoma, also a plasma cell tumor, is very rare in the gastrointestinal tract and the pancreas, and only a handful cases have been documented till now. Gastric and pancreatic plasmacytomas are usually seen in elderly patients; however, cases in patients as young as 32 years of age have been reported. Commonly, patients with gastric plasmacytoma present with nonspecific symptoms like epigastric pain, abdominal fullness, anorexia, and weight loss, or serious conditions like massive upper gastrointestinal bleeding and gastric outlet obstruction. Patients with pancreatic plasmacytoma commonly present with obstructive jaundice. In this article, we present the case of a 79-year-old man with a history of MM for 3 years, diagnosed with gastric and pancreatic masses, which turned out to be plasmacytomas. To our knowledge, simultaneous occurrence of gastric and pancreatic plasmacytomas is extremely uncommon with less than 5 cases reported in the literature. We also compiled all the individual cases of gastric and pancreatic MM that have been reported in literature till now.

An Innocent Esophageal Mucosal Bridge: Case Report and Literature Review

An esophageal mucosal bridge is a rare finding that is seldom encountered on upper endoscopy. They most commonly present secondary to an underlying inflammatory disorder and cause chest pain and dysphagia, among other symptoms. More rarely, they present asymptomatically with no identifiable inflammatory conditions. Our case consists of a 31-year-old woman who presented with an asymptomatic, noninflammatory mucosal bridge of the esophagus. To our knowledge, this makes the third such case. The rarity of this condition coupled with the lack of epidemiologic data available make this case worthy for literature review.

Endoscopic ultrasound-guided management of bleeding periampullary tumor

A 72-year-old man presented with melena and a drop in hemoglobin from 10g/dL to 5g/dL. He required three units of blood for hemodynamic stabilization. He had undergone endoscopic retrograde cholangiopancreatography (ERCP) with biliary plastic stenting 4 days previously for a periampullary tumor. On side-viewing endoscopy, a blood clot covering the tumor was found and removed, with 20mL of 1:10000 epinephrine injected to achieve hemostasis (▶Fig. 1). A repeat side-viewing endoscopy on the second day showed no active bleeding. However, he bled massively after 48 hours and was sent for CT angiography which revealed ampullary mass without any demonstrable source of bleeding. An endoscopic ultrasound (EUS) examination demonstrated the course of the blood vessels proceeding towards the tumor (▶Fig. 2 a; ▶Video1). An EUS-guided intervention was planned to control the periampullary bleeding, keeping in mind the normal blood supply to the ampulla. A 25-gauge EUS needle was used to puncture one of the branches of the gastroduodenal artery (GDA) closer to the second part of the duodenum and 1mL of 99.9% absolute alcohol was injected (▶Fig. 2b). A further 1mL of alcohol was injected around another branch proceeding towards the tumor in a periarterial location (▶Fig. 2 c). Following this EUS-guided alcohol injection, repeat side-viewing endoscopy showed no active bleeding. Unfortunately, the patient did rebleed again on day 6, with active ooze around the ampullary growth. Emergency Whipple’s procedure was not considered given the patient’s unwillingness to undergo such surgery at that time. Therefore, EUS-guided coiling of the GDA was planned as a salvage treatment. The transducer was placed in the antrum parallel to the GDA so that its diameter could be measured to select the size of microcoil required (▶Fig. 3 a). The GDA was punctured with a 22-gauge needle under EUS guidance and two microcoils of 4mm in size were placed (▶Fig. 3b; ▶Video1). Repeat side-viewing endoscopy showed no active bleeding. The patient later underwent a Whipple’s procedure, which showed well-differentiated ampullary adenocarcinoma.

Rectal leiomyoma, a rare entity

Rectal tumors are often encountered as an incidental finding on screening colonoscopy. As per the World Health Organization, they are categorized according to their histologic appearance. These include epithelial tumors, mesenchymal tumors and lymphomas. Of interest, in our case, are mesenchymal tumors. These are sub-classified into leiomyomas and gastrointestinal stromal tumors. Our case is a 33-year old male who was diagnosed with a rectal leiomyoma. The uncommon incidence and subsequent management of a rectal leiomyoma in a male, make this case worthy for literature review.

Gastric mucosal prolapse: A case of proton-pump inhibitor nonresponsive dyspepsia

Gastric mucosal prolapse (GMP) is a rare clinical syndrome that in patients with hiatal hernias and gastroesophageal reflux disease (GERD) may present with typical findings of abdominal pain and reflux symptoms but prove resistant to medical therapy. Physicians should therefore be aware and consider GMP as a differential in such patients in order to make an accurate diagnosis and provide timely treatment.