Colonoscopies have reduced colorectal cancer (CRC) burden in the United States, and their utility has expanded to include various diagnostic and therapeutic indications. Complications are seen in up to 1% and increase with age and polypectomy. As colonoscopies become widespread, specific populations seem to be at a much higher risk; notably patients with heritable connective tissue disorders (HCTD). As life expectancy increases, these patients undergo routine screenings and require careful peri-endoscopic care to reduce adverse outcomes. Amongst HCTD, Ehlers-Danlos syndrome (EDS) is commonly implicated, however, no reports of Marfan syndrome (MS) exist. We present a unique case of splenic injury after colonoscopy in a patient with MS. Successful outcomes require early suspicion and emergent surgical evaluation in patients with hemodynamic instability after a colonoscopy. Increased ligament laxity and bowel fragility are the most likely mechanisms. Alternative CRC strategies like fecal immunochemical test (FIT), fecal occult, Cologuard, or virtual colonography can be considered.
Celiac disease (CD) is an autoimmune disorder that predominantly affects the small intestine and is related to antibodies created against gluten when the substance is ingested. It is uncommon comorbidity in patients with Hashimoto's thyroiditis (HT). Myxedema is a severe form of hypothyroidism that is commonly related to new diagnoses, medication non-compliance, or malabsorption of thyroid supplementation that can have life-threatening associated conditions like heart failure and coma. In this article, we will describe a case of myxedema secondary to levothyroxine malabsorption in the setting of a newly diagnosed CD.
Introduction: Nissen fundoplication has been an effective and safe procedure for the treatment of refractory gastroesophageal reflux disease (GERD), however, post-surgical complications can arise. We describe a 69-year-old female with a history of Nissen Fundoplication who presented due to dysphagia and concern for food impaction. The patient was found to have an ischemic distal esophagus and perforated gastric mucosa, severe and rare complications of laparoscopic fundoplication, requiring emergent resection. Case Description/Methods: A 69-year-old female with a history of refractory GERD who had a Nissen fundoplication performed seven months prior presented to the ER with dysphagia. The patient reported eating pork the night prior when she felt as if a piece became stuck in her lower chest after swallowing. Following this, the patient experienced an inability to swallow any liquids or solids without regurgitation. Labs including CBC, chemistries, and lactic acid were unremarkable. She underwent urgent esophagogastroscopy, showing a small gastric pouch with retained contents. There was difficulty insufflating the stomach, with friable gastric mucosa and spontaneous bleeding. The esophagogastroscopy (EGD) was aborted and the patient was sent for stat contrasted computed tomography (CT), which showed a large paraesophageal hernia with concern for a gastric volvulus and free fluid surrounding the intrathoracic stomach. The patient ultimately went to the operating room where it was discovered that a large portion of the patient's stomach had herniated through her fundoplication wrap. Release of the fundoplication and resection of the ischemic distal esophagus and proximal stomach were performed. The patient required transfer to a tertiary care center for reconstruction. (Figure ) Discussion: Current guidelines recommend pH monitoring, EGD, and esophageal manometry prior to anti-reflux surgery. The patient's initial high-resolution manometry had findings concerning for possible achalasia. She was reevaluated at a tertiary center with a negative dysmotility work up, deeming her a surgical candidate. Failures of surgery usually occur within two years after operation. The majority of complications are due to breakdown in the structural integrity of the wrap. Late gastric perforation is a rare complication with sparse literature. Careful review of preoperative studies are key to prevent drastic outcomes and endoscopists should keep this in mind with atypical presentations of food impaction in an emergency setting.
INTRODUCTION: Esophageal food impaction is one of the more common GI emergencies. While endoscopy is the definitive therapy, pharmacologic therapy does have a role. Despite minimal success, because of the safety profile glucagon is currently recommended as the initial pharmacologic therapy.1–5 Effervescent agents have been limited due to previous concerns of perforation, but studies have been revisited recently with safety and success.5–7 Our aim is to measure EG and glucagon as a primary pharmacologic agent. METHODS: A retrospective study was performed on all patients over 18 between 6/2015-5/2018, with diagnosis of esophageal obstruction or foreign body. Exclusion was transfer to outside facility. Records were reviewed for administration of glucagon and/or effervescent granules, if relief of obstruction was achieved, patient's ability to tolerate secretions and food responsible. Etiology was determined from history, endoscopy report, imaging, and pathology. T-test was performed for statistical significance. RESULTS: Demographic data, along with food bolus types and diagnoses can be found in Table 1. EG was attempted as an initial modality in 20.2% of cases and glucagon in 16.8%. EG was more successful when compared to glucagon (51.2 % vs 14.7%) (P = 0.0216). EG was successful as secondary modality in 75% of cases after glucagon initially failed, as compared to glucagon in 0% (0/9) of cases when EG initially failed (P = 0.0094). Figure 1 highlights success of EG and Glucagon based on diagnosis. There were no major safety events. CONCLUSION: Overall, EG is safe; and appears to overall be more efficacious than glucagon as initial pharmacologic therapy for EFI. This is a worthwhile therapy for both those who are tolerating secretions and those who are not, while glucagon seems to be more effective for secretion tolerant patients. EG was highly successful in patients tolerating secretions, however with a success rate of over 50% with no complications, we suggest it is worth attempting even in those who are not.
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