Current guidelines recommend management of benign gastric outlet obstruction (GOO) with serial dilations. Self-expanding metal stents are effective, but their use is complicated by high rates of migration. We present two cases from our institution where a uniquely designed, lumen-apposing metal stent (LAMS) was successfully used to alleviate benign GOO without stent migration.
The detection and quantification of coronary artery calcification (CAC) significantly improves cardiovascular risk prediction in asymptomatic patients. Many have advocated for expanded CAC testing in symptomatic patients based on data demonstrating that the absence of quantifiable CAC in patients with possible angina makes obstructive coronary artery disease (CAD) and subsequent adverse events highly unlikely. However, the widespread use of CAC testing in symptomatic patients may be limited by the high background prevalence of CAC and its low specificity for obstructive CAD, necessitating additional testing (‘test layering’) in a large percentage of eligible patients. Further, adequately powered prospective studies validating the comparative effectiveness of a ‘CAC first’ approach with regards to cost, safety, accuracy and clinical outcomes are lacking. Due to marked reductions in patient radiation exposure and higher comparative accuracy and prognostic value make coronary computed tomographic angiography the preferred CT-based test for appropriately selected symptomatic patients.
INTRODUCTION:
Iatrogenic colonic perforations are an infrequent complication of endoscopy that often require immediate surgical repair. However, endoscopic suturing devices or endoscopic clips are increasingly being utilized for closure. Through-the-scope clips can have high rates of failure and often require multiple clips per closure to achieve a similar level success to over-the-scope clips. Ovesco over-the-scope clips (OTSC®) have been studied in small prospective studies with 89% successful closures of acute iatrogenic gastrointestinal perforations without adverse events1. More recently, the Padlock Clip® defect closure system has emerged as a newer over-the-scope clip with case reports showing high levels of efficacy and safety in a variety of uses. We present a case of iatrogenic colonic perforation repaired with the Padlock Clip with a concurrent laparoscopic air-leak test confirming immediate complete closure.
CASE DESCRIPTION/METHODS:
A 64-year-old female with a history of severe diverticulosis presented for routine colonoscopy for polyp surveillance. The patient became significantly uncomfortable with water irrigation and a perforation was identified approximately 20cm from the anal verge, likely consistent with a perforated diverticulum. The procedure was aborted with subsequent imaging confirming a sigmoid colon perforation. In the operating room, a Padlock Clip defect closure device was endoscopically deployed with subsequent laparoscopic leak test confirming immediate air-tight seal. A diet was subsequently initiated without evidence of a leak.
DISCUSSION:
This case illustrates the efficacy of an alternative over-the-scope clip in closure of an acute colonic perforation. Compared to prior over-the-scope clips, the Padlock Clip is easier to deploy with potentially similar rates of efficacy and safety. The design of the Padlock Clip better facilitates two-person deployment as opposed to the Ovesco OTSC®. The deeper cap length makes acquisition of tissue easier and obviates the need for additional graspers. This patient demonstrates the Padlock Clip system as a viable option for the management acute iatrogenic colonic perforations. Reference: 1Voermans RP, Le moine O, Von renteln D, et al. Efficacy of endoscopic closure of acute perforations of the gastrointestinal tract. Clin Gastroenterol Hepatol. 2012;10(6):603-8.
INTRODUCTION:
Polyposis syndromes are rare and often undiagnosed or misdiagnosed in clinical practice. Presented here is a case of Cowden syndrome initially misdiagnosed as an atypical presentation of ulcerative colitis.
CASE DESCRIPTION/METHODS:
A 62-year-old male presented to the gastroenterology clinic for routine annual surveillance colonoscopy. He had undergone numerous colonoscopies for the past decade demonstrating pseudopolyps throughout the colon. Pathology revealed normal colonic mucosa, hyperplastic features, and inflammatory polyps. He denied a history of diarrhea or hematochezia, or a family history of inflammatory bowel disease. The patient was ultimately diagnosed with ulcerative colitis, placed on oral mesalamine treatment, and advised to undergo annual colonoscopy for dysplasia surveillance. On the date of encounter a thyroidectomy scar was noted on physical exam. The patient had undergone total thyroidectomy in the 1990’s for an unknown reason. Chronic lesions resembling papillomas were present on his buccal mucosa. Although he did not have a formal diagnosis of autism, the patient displayed several characteristics of the disorder throughout the encounter. The patient’s son had also been diagnosed with numerous non-adenomatous colon polyps and his father had passed from renal cell carcinoma. Given clinical suspicion for Cowden syndrome, an upper endoscopy was added to the annual colonoscopy demonstrating significant esophageal glycogenic acanthosis and extensive duodenal hamartomas. Colonoscopy again demonstrated numerous hamartomas throughout the colon. Genetic sequencing demonstrating a frame shift mutation in the PTEN gene was performed by Athena Diagnostics, diagnostic of Cowden syndrome. Subsequently his mesalamine was discontinued, his colonoscopy surveillance interval was increased to every five years, and annual screening for renal cell carcinoma screening was initiated. His son was advised to undergo genetic testing as well due to the syndrome’s autosomal dominant inheritance pattern.
DISCUSSION:
This case showcases the utility of highlighting rare clinical entities. The prevalence of Cowden syndrome is estimated to be only 1 in 200,000 to 250,000 individuals. Clinicians are proficient at diagnosing more common disease presentations; however, rare disorders such as polyposis syndromes can be unrecognized unless they are consistently reviewed outside of daily practice.
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