Vishal Ghevariya

Carcinoid Tumors of the Gastrointestinal Tract

The gastrointestinal tract is the largest neuroendocrine system in the body. Carcinoid tumors are amine precursor uptake decarboxylase (APUD) omas that arise from enterochromaffin cells throughout the gut. These tumors secrete discrete bioactive substances producing characteristic immunohistochemical patterns. Most tumors are asymptomatic and detected at late stages. Hepatic metastases are commonly responsible for carcinoid syndrome. The small bowel is the most common location of carcinoids. Computed tomography scan and magnetic resonance imaging are useful in the detection of these tumors. The measurement of bioactive amines is the initial diagnostic test. Various treatment options, including somatostatin analogs, interferon, chemotherapy, surgery, hepatic artery chemoembolization, and surgery have emerged in the past two decades. However, the incidence and prevalence of carcinoid tumors has increased, while mean survival time has not changed significantly. The lack of standardized classification, federal support, and an incomplete understanding of the complications of this disease are some of the impediments to progress in treatment.

Treatment of Persistently Leaking Post PEG Tube Gastrocutaneous Fistula in Elderly Patients with Combined Electrochemical Cautery and Endoscopic Clip Placement

Objectives: Persistent leakage from a gastrocutaneous fistula (GCF) created for the purpose of percutaneous endoscopic gastrostomy (PEG) tube placement is a common problem in elderly patients. Conservative methods often prove unsuccessful and surgical closure is usually not performed because of poor surgical risk. With advances in endoscopic technology, several nonsurgical approaches have emerged. These new methods have been reported in the past as case reports. The purpose of this study is to report a case series of eleven elderly patients with persistent leakage from gastrocutaneous fistulas who underwent combined electrochemical cautery and endoscopic clip placement. Methods: Eleven patients had failed conservative therapy and were deemed unsuitable candidates for surgical closure. Electric and chemical cauterization was used to de-epithelialize the fistulous tract. The edges of the internal orifice of the gastrocutaneous fistula were approximated using endoclips during an esophagogastroduodenoscopy. Patients were observed postprocedure for leakage. Results: This procedure resulted in complete closure of the gastrocutaneous fistula in nine patients (82%). One patient had partial closure of the fistula which was sealed using a new PEG tube. Conclusion: Gastrocutaneous fistula is a common complication in elderly patients after removal of gastrostomy tubes. Simple endoscopic procedures have shown promising results in the treatment of this complication.

Knowing what's out there: awareness of non-alcoholic fatty liver disease

Background: Non-alcoholic fatty liver disease (NAFLD) is the most common hepatic disorder, which poses a significant health burden in the western countries. As the epidemic of obesity slides health downward, the incidence of NAFLD is evidently increasing. Aim: We aimed to ascertain the awareness of NAFLD and its risk factors in the general population, which may be helpful in designing educational tools to promote prevention, early detection, and treatment of this disorder. Methods: A survey of 5000 non-institutionalized residents of Brooklyn, NY, USA was conducted. Sixteen items were included in the survey questionnaire including awareness of fatty liver, predisposing factors of NAFLD, awareness of cirrhosis, and conditions that advance to cirrhosis. The questionnaire also addressed awareness of prevention, diagnostic methods and treatment of NAFLD, and education of physicians to their patients about NAFLD. Results: Overwhelming majority of the subjects was not aware of NAFLD and stated that their physicians did not have a discussion about NAFLD. Conclusion: Non-alcoholic fatty liver disease is a preventable liver disorder with limited treatment options. Thorough counseling by primary care physicians can be of paramount importance in preventive strategy for NAFLD. We should target our teenage population in an era of obesity epidemics of all times.

Splenic injury from colonoscopy: a review and management guidelines.

Splenic injury is an uncommon complication of colonoscopy. Less than 100 cases are reported in the English language literature. The exact mechanism of injury to the spleen during colonoscopy is unknown; various authors propose several risk factors and possible mechanisms. Splenic injury can be graded or classified according to the extent of laceration and the severity of the resultant hematoma. The management options range from observation to emergency splenectomy. Computed tomography scan is the most important imaging modality to diagnose splenic injury. Early recognition and appropriate management is of paramount importance in the management of this condition. A high index of suspicion in a patient with persistent abdominal pain after colonoscopy is key especially when a perforated viscous is ruled out. This article outlines the clinical presentation of splenic injury after colonoscopy and delineates a management algorithm.

The skin: a mirror to the gut.

IntroductionThis review discusses the diseases with involvement of both skin and gut. GI manifestations of vesicobullous disorders and systemic diseases and syndromes involving skin and gut, dermatologic manifestations of inflammatory bowel disease (IBD), polyposis syndromes, and GI malignancies have been discussed. Diagnostic and treatment approaches towards these disorders are summarized.ConclusionsInteraction of the skin and gut has always been an area of inquisitiveness. Gastrointestinal (GI) tract can be involved in dermatological disorders or GI diseases can have a dermatological manifestation.

Giardiasis and Nodular Lymphoid Hyperplasia of the Duodenum.

A 29-year-old Hispanic man presented with abdominal pain and chronic diarrhea. The results of the initial work-up were unremarkable. Esophagogastroduodenoscopy revealed duodenal nodules (a). Histology revealed nodular lymphoid hyperplasia (NLH) (b, arrows) and parasites, morphologically consistent with Giardia lamblia (c, arrows). NLH of the gastrointestinal tract is a rare and benign lymphoproliferative disorder characterized by the presence of nodules (<10 mm) distributed along the small bowel, stomach, colon, and rectum. The pathogenesis of NLH is unknown, but it has been associated with several conditions. The clinical presentation is variable and depends on the size and extent of the nodules as well as the patient’s immune status. The diagnosis is based on specific pathological findings. Treatment is directed toward the associated conditions, which include intestinal and extraintestinal lymphoma. The role of surveillance is controversial. Our patient was deemed immunocompetent and treated successfully with a course of metronidazole.

Tracheoesophageal voice prosthesis: endoscopic appearance

Total laryngectomy is surgical removal of the entire larynx and stoma creation for air entry into the trachea, which results in aphonia. Tracheoesophageal puncture with placement of a voice prosthesis provides comprehensible esophageal speech. This voice prosthesis is a conduit with a 1-way valve inserted surgically between the trachea and the esophagus. A tracheoesophageal voice prosthesis was noted in the upper esophagus during upper endoscopy (A).

Ruptured varix: tips to tackle the demon

Endoscopic ligation of esophageal varices is a common endoscopic procedure. In an event of failed rubber-band ligation of a varix, profuse bleeding can develop from a variceal rupture. A cirrhotic patient presented with hematemesis. Three fibrin-platelet plugs were noted adjacent to one another, just above the gastroesophageal junction (Fig. 1). Two plugs were noted on a single varix and could be caught with a single band. However, the second ligation failed, resulting in profuse bleeding. Pressure hemostasis, performed by using the tip of the band ligator cap, was achieved promptly while a sclerosant was being prepared. Successful hemostasis was achieved with sclerotherapy and pressure application. This video also demonstrates the use of auxiliary water jet irrigation

Aortoesophageal fistula with aortitis: endoscopic management

Aortoesophageal fistula is a known adverse event of stent graft repair of aortic aneurysm. This entity commonly presents with GI bleeding, which is frequently fatal. We describe a case of aortoesophageal fistula with accumulation of debris within the aneurysmal sac, resulting in anemia (hemoglobin 9.5 g/dL, baseline 10.5 g/dL), melena, aortitis, and severe sepsis. Endoscopic debridement was performed, followed by covered metal esophageal stent placement, with resolution of sepsis (Video 1, available online at www.giejournal.org). Our intervention may have reduced a systemic infectious/inflammatory response and provided tamponade of the aortic sac.

Celiac artery compression: EUS evaluation

A 51-year-old man was seen for evaluation of abdominal discomfort. The discomfort was epigastric and nonradiating and was accompanied by heartburn without specific aggravating and/or alleviating factors. The patient denied nocturnal and/or postprandial association and weight loss. The patient’s laboratory evaluation results were within normal limits. A CT scan revealed stenosis of the celiac trunk with poststenotic dilation measuring 8.6 mm (Fig. 1; Video, available online at www.giejournal.org.). The CT scan and transabdominal US could not delineate the etiology of the celiac compression clearly. EUS was performed at the time of EGD. The median arcuate ligament arises from the crus of the diaphragm and