Introduction:The risk of colonic perforation from a colonoscopy was found to be 0.03-0.8%. The risk of a fistula occurring after colonic anastomosis can be up to 10%. Currently, management has included fully covered self-expanding metal stents, endoscopic clipping with suturing, and endoscopic vacuum therapy. Case Description/Methods: We present a 61-year-old female patient, with a past medical history of hypertension, hyperlipidemia, gout, end-stage renal disease on peritoneal dialysis and awaiting kidney transplant who underwent a screening colonoscopy and had an iatrogenic perforation of the rectosigmoid area at 20cm from the anal verge from a presumed perforated diverticulum. Management consisted of an Exploratory Laparotomy with sigmoid colectomy and primary anastomosis. Four months later, the patient presented with passing stool through her vagina, consistent with a colo-vaginal fistula. She was admitted, and she underwent colonoscopy where an EGD scope was advanced about 12-15cm to the anastomosis site; however, it was difficult to identify the site of the fistula. A 50-50% mixture of cyanoacrylate and lipid oral solution were injected submucosally. Then, a 23mmx12cm fully covered esophageal stent was deployed with subsequent single stentfix OTSC clip from OVESCO was applied. Few days after the procedure, the patient was diagnosed with pneumoperitoneum without significant peritonitis, and this was managed conservatively. A month later, she underwent flexible sigmoidoscopy with removal of stentfix clip and the stent. There was a large ulceration from the stent dilation at the anastomosis site. Due to the size of the ulcer, no intervention was performed. Her pelvic pain resolved and she stopped passing stool through her vagina, but she continued to pass air through her vagina. Subsequent barium X-ray revealed a persistent colo-vaginal fistula, and flexible sigmoidoscopy was attempted 3 weeks later to help close the colo-vaginal fistula. The scope was advanced into the vagina and with the help of a catheter, a 021G guidewire was passed from the vagina through the fistula into colonic anastomosis. A Padlock clip was attached to the tip of the endoscope and inserted into the rectum. The fistula was centered with the help of the guidewire into the Padlock clip and the clip was released successfully. The guidewire was then pulled out from the vagina. Discussion: This case demonstrates a unique approach for patients with colo-vaginal fistulas for whom traditional techniques are unsuccessful.
ObjectiveTo determine the significance of baseline hypercoagulable status as an independent risk factor for premature CAD (coronary artery disease) in a south Asian migrant population.BackgroundAtherosclerosis is the leading cause of mortality in United States and other industrialized countries. South Asian immigrant is the largest ethnic group in United States with a much higher incidence of CAD as compared with the Framingham study. Thus, an effort needs to be made to search for other modifiable risk factors, especially in this population.MethodsAn arterial hypercoagulabe workup was performed on all the south Asian patients with angiographically proven premature CAD at an inner-city community hospital between a period of 1998 to 2002.ResultsAn increased propensity for arterial hypercoagulability was display by 17.85% of the studied population, in the form of elevated homocysteine, fibrinogen, and antiphospholipid antibody levels.ConclusionsConsidering the increased prevalence and the potential mortality and long-term morbidity of CAD, an arterial hypercoagualablity workup is worth considering in a south Asian population with premature CAD.Condensed AbstractCAD is one of the major killers of industrialized countries. Starting from the Framingham study, several studies have been performed to find out the risk factors and the ways to modify them to decrease the incidence of CAD. South Asian migrants in the United States constitute a unique subset of patients with a higher than expected incidence of CAD. We tested for arterial hypercoagulability a population of south Asian migrants with an angiographically proven diagnosis of premature CAD in an inner-city community hospital from 1998 to 2002. We found an incidence of 17.85% positive hypercoagulable workup in this group.
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