Collagenous gastritis is a rare histopathologic entity that causes marked subepithelial collagen deposition in the gastric mucosa. Clinical presentation is diverse, considering only less than 100 cases have been reported. However, we report a unique case of isolated collagenous gastritis in a 71-year-old female who presented with a 6-month history of dyspepsia and 27 kg weight loss. Her endoscopic findings revealed a tubular shaped stomach with diffuse gastric mucosal atrophy, findings that differ with previous case reports of a cobblestone pattern. Treatment remains unclear.
Sigmoid volvulus is a rare condition seen during pregnancy with high maternal and fetal morbidity and mortality. We report a case of a young 26-year-old woman, primipara, in her third trimester who presented with recurrent sigmoid volvulus at both 30 and 32 weeks of gestation. She underwent successful repetitive endoscopic decompression on both admissions with uneventful recovery. Endoscopic evaluation is safe in pregnancy and uncomplicated volvulus. It allows for diagnostic confirmation and assessment of complications; and it has successful outcomes in the presence of a multidisciplinary team.
A 65-year-old Hispanic female presented with a one-year history of anorexia, nausea, early satiety, epigastric discomfort, and a 20 kg weight loss. Computed tomography (CT) demonstrated heterogeneous liver parenchyma. Upper endoscopy revealed large, fungating, infiltrative mass at the lesser gastric curvature incisura, highly suspicious of gastric tumor; however, initial biopsy of the gastric mass was equivocal and an exploratory laparoscopy was performed. Repeated intraoperative biopsies of the gastric mass and of liver parenchyma demonstrated diffuse hyalinized stroma consistent with amyloid deposition, and a bone marrow biopsy confirmed the diagnosis of primary light chain (AL) amyloidosis.
INTRODUCTION: Ectopic varices are unusual and can involve any site along the GI tract. Only 5% of variceal bleeding is related to ectopic varices such as duodenal varices. Ectopic variceal bleeding is usually massive, difficult to treat, and associated with high mortality rates. High clinical suspicion is warranted. No standardized treatment is recommended, and the management remains challenging with limited success in controlling recurrent bleeding. EUS-guided therapy has evolved as an effective therapeutic modality in gastric varices and this case demonstrates the role of EUS-guided coil embolization (EUS-CE) with cyanoacrylate (CYA) injection in the management of duodenal variceal bleeding. CASE DESCRIPTION/METHODS: 81-year-old female with history of Diffuse large B cell lymphoma on chemotherapy presented with intermittent massive upper gastrointestinal bleeding. CT abdomen showed cirrhotic liver and portal vein thrombosis due to lymphoma involvement. Three endoscopies performed over a period of 5 days revealed 1 cm non-bleeding duodenal ulcer at the duodenal sweep without stigmata of recent bleeding. Due to recurrent bleeding, empiric coil embolization of the gastroduodenal artery and multiple duodenal branches through angiography was done by interventional radiology. However, severe bleeding recurred after the embolization, and the fourth urgent EGD showed large subepithelial violaceous lesions next to the deep penetrating ulcer, highly suspicious for duodenal varices. EGD-EUS confirmed these lesions were duodenal varices. By the fifth day of admission, patient had required 8 units of PRBC. Therefore, the decision was made to treat with EUS-CE. Two coils of 8 and 9 mm were deployed into the larger varix through a 19G EUS-FNA needle followed by 2 ml injection of CYA. A third 6 mm coil was also deployed in the feeder vessel also followed by CYA. Both lead to embolization and cessation of blood flow as demonstrated through Doppler investigation at the end of the procedure. Bleeding stopped and patient was discharged home to complete chemotherapy. DISCUSSION: Bleeding from duodenal varices require high suspicion as vessels could be miss if collapsed soon after bleeding. High clinical suspicion can result in early angiographic evaluation and intervention. Ideal management of ectopic variceal bleeding is still unclear. Multiple endoscopic technique modalities have been reported. EUS-CE with or without CYA injection is a safe endoscopic technique with effective variceal obliteration in most cases.
INTRODUCTION: Despite multiple endoscopic hemostatic devices available, GI bleeding can still be difficult to treat. A new hemostatic device was recently approved by the FDA as an non-surgical treatment option of upper and lower GI bleeding. The hemostatic powder forms a mechanical and adhesive barrier by absorbing water and promotes thrombus formation by concentrating and activating platelets and coagulation factors with high primary hemostasis rates. It has been reported as a successful hemostatic technique for common causes of GI bleed, but not for pseudocyst bleeding. CASE DESCRIPTION/METHODS: 84-year-old male admitted to our institution ten days after a surgical cystgastrostomy with one day history of abdominal pain associated with nausea and vomiting. Hemoglobin decreased from 11 to 8 mg/dl after the surgery and occult blood in stool was positive. Initial CT angiogram revealed no active bleeding but a large complex fluid collection 13.1 × 11.6 × 12.9 cm from the pancreatic tail and involving the stomach. Gastroenterology was consulted to assess the cystgastrostomy patency and evaluate for GI bleeding as the cause of anemia. Endoscopy was performed and revealed that the pseudocyst gastrostomy in the proximal gastric body had stenosed to 0.5 cm from 6 cm and the pseudocyst cavity was filled with large clots but no evidence of active bleeding. Due to the stenosis, double pig tail plastic stents were placed. Patient developed melena and hemoglobin decreased again from 9 to 7 mg/dl. Repeated endoscopy revealed active bleeding within the pseudocyst wall near the anastomosis. The tissue was very friable. Epinephrine injection, coaptive coagulation with bipolar cap and hemostatic clip placement were all unsuccessful to stop the bleeding. Finally, hemostasis was achieved using a new hemostatic powder through endoscopic delivery catheter. The powder was sprayed successfully to the anastomosis and proximal cavity of the pseudocyst without complication or further bleeding. Follow up a month later did not showed any evidence of active bleeding. Repeat CT abdomen revealed decreased in size of the pancreatic pseudocyst with plastic stents still in place. DISCUSSION: To our knowledge, this is the first report of the use of hemostatic powder delivered via endoscopy outside the GI tract to achieve hemostasis from pancreatic pseudocyst wall bleeding. This device can be considered as a rescue modality for those cases where the standard treatment has failed. Further studies are needed to assess its safety in this setting.
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