No abstract

Introduction: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the standard diagnostic method for sampling mediastinal and hilar lymph nodes. Non-diagnostic samples have led some pulmonologists to add a miniforceps biopsy (EBUS-TBFB) in order to increase diagnostic yield. Our study aims to analyze the impact of adding EBUS-TBFB to the EBUS-TBNA in cases where Rapid On-site Evaluation (ROSE) was negative for malignancy or was non-diagnostic. Material and methods: This retrospective chart review included 91 patients who were aged 18-90 years old and underwent EBUS with both TBNA and TBFB between January 1, 2013 and July 1, 2018. Results: There was no significant statistical difference in the diagnostic yield of TBNA vs TBFB with a McNemar value of 0.167, and this conclusion was the same when stratified by race, age and lymph node size. Using TBNA as a gold standard, the sensitivity and specificity of TBFB was 87% and 69%, respectively. Out of the non-diagnostic TBNA samples on ROSE and cell-block, subsequent TBFB resulted in additional pathologic diagnoses in 16% of cases, of which 67% were non-caseating granulomas. Furthermore, two additional malignant cases were identified by TBFB consisting of small cell carcinoma and non-Hodgkin's lymphoma. Conclusion: In conclusion, TBFB is a useful adjunctive tool in the diagnosis of non-malignant conditions (i.e. granulomatous diseases) with the potential to spare the patient from more invasive surgical biopsies. Training of future fellows in performing TBFB in addition to TBNA should be strongly encouraged.

No abstract

No abstract

INTRODUCTION: Duodenal diverticula are relatively common findings in the small bowel with reported prevalence ranging between 0.6–22%. The vast majority of them are asymptomatic and found incidentally. We present an unusual case of hemorrhagic shock resulting from bleeding duodenal diverticula. CASE DESCRIPTION/METHODS: A 46-year-old male with history of alcohol abuse presented with 1-day history of multiple episodes of hematochezia and dark tarry emesis. He had associated lightheadedness, dyspnea, diaphoresis along with 1 episode of syncope. He did not use any medications on regular basis. His heart rate was 125 beats/minute and blood pressure 99/53 mmHg. Labs included hemoglobin (Hgb) of 4.5 gm/dL, platelets 75000/mcL, creatinine 1.81 mg/dL and lactic acid 4.4 mmol/L. Patient was subsequently intubated for airway protection due to recurrent episodes of hematemesis. An esophagogastroduodenoscopy (EGD) showed 3 large diverticula in the second portion of duodenum with active bleeding noted from a non-periampullary proximal diverticulum (Figure 1). Hemostasis was achieved with epinephrine injection followed by Hemospray. A follow up arterial angiogram was unremarkable. Patient experienced recurrent bleeding within 48 hours requiring 2 additional EGDs with therapeutic interventions (epinephrine, ablation and endoclips). Repeat angiography was done due to persistent drop in Hgb. This time, an area of irregularity in one of the gastroduodenal artery branches was identified adjacent to the previously placed endoclips. Coil embolization was performed successfully with excellent results. Patient’s condition eventually stabilized without any recurrent bleed. Upon follow up, his Hgb was 10.7 gm/dL 3 weeks after discharge. DISCUSSION: The majority of duodenal diverticula are asymptomatic. About 1% result in complications requiring definite endoscopic or surgical intervention. Potentially fatal bleeding represents minimal proportion of these complications and its management can be challenging. Our case demonstrates an extreme example of massive gastrointestinal bleeding that was difficult to control despite multiple endoscopic interventions. Initial angiography was not successful to identify the bleeding. Applying endoclips helped to subsequently localize and control the source of bleeding in the second angiogram. Using this approach can be an invaluable asset in such conditions.

No abstract

No abstract

No abstract