Dieulafoy's lesion accounts for 1%-2% of acute gastrointestinal (GI) bleeding cases, and approximately 2% of Dieulafoy's lesions are present in the colon. We report the case of an 83-year-old female who presented with recurrent gastrointestinal bleeding from colonic Dieulafoy's lesion located at the hepatic flexure. She initially presented four weeks prior with melena in the setting of Eliquis use for venous thrombosis, coronary artery disease, and end-stage renal disease. Upper endoscopy revealed esophagitis, gastritis, and duodenitis. Diagnostic colonoscopy and video capsule endoscopy both revealed blood in the colon without an identifiable source. During the second admission for recurrent melena with hemoglobin of 3.9 g/dL, Eliquis was discontinued, and the patient was resuscitated with three units of packed red blood cell transfusions. Repeat colonoscopy revealed a pulsating vessel with active oozing located at the hepatic flexure, consistent with a Dieulafoy's lesion. Hemostatic endoclips and bipolar electrocautery were applied to achieve complete hemostasis. Colonic Dieulafoy's lesions, albeit rare, should be considered in patients presenting with an acute obscure lower GI bleed. Primary hemostasis can be achieved with several endoscopic modalities including epinephrine, hemoclipping, thermocoagulation, or sclerotherapy.
Figure 1. A) Computed Tomography scan image demonstrating the thickened ureters (yellow arrows) mainly on the right side with the double J-stents seen inside their lumen. Endoscopic images of the gastric body (B, C) demonstrate thickened, edematous gastric mucosal folds, with a waffle-like appearance, that did not flatten with insufflation consistent with linitis plastica.
Introduction: Gastrointestinal (GI) sites of metastatic breast cancer (BC) are rare, compared to more frequent sites of bone, lung and brain. Incidence of stomach metastasis from primary tumors is , 1-2%, and according to literature as low as 0.3% from primary BC. The hormone receptor profile of metastatic sites is discordant in up to 15% of cases with triple negative metastatic sites from primary hormone receptor positive tumors. We present a case of metastatic BC to the stomach with tumor discordance. Case Description/Methods: A 49-year-old African American female was admitted after undergoing an esophagogastroduodenoscopy (EGD) for complaints of progressive dysphagia, 50 lb. weight loss, and reflux for 6-months. 10-years ago, patient was diagnosed with Stage II estrogen receptor (ER) and progesterone receptor (PR) positive, human epidermal growth factor receptor 2 (Her-2/neu) negative, invasive ductal carcinoma with lobular features. She underwent right breast lumpectomy and was treated with tamoxifen successfully. 4-years ago, inflammatory breast changes and flank pain revealed cancer recurrence with osseous metastasis. She was treated with several hormonal chemotherapies and radiation, and her disease was stable on a positron emission tomography scan 6-months ago. Bone marrow biopsy 1-month ago revealed ER/PR1 disease with PIK3CA gene mutation, with a treatment regimen of alpelisib and fulvestrant. EGD revealed nodular, erythematous, friable mucosa at the distal esophagus, causing inability to transverse EGD scope further (A). EGD scope was changed to ultraslim endoscope and advanced to show gastric mucosa that was nodular, friable, with ulcerations that bled upon contact with endoscope (B). Immunohistochemistry stain (IHC) of gastric biopsies revealed ER/PR/Her-2/neu negative (triple negative), cytokeratin 7 (CK7) and GATA binding protein 3 (GATA3) positive, metastatic breast carcinoma (C,D). Surgery was consulted for jejunostomy tube placement to provide nutrition and confirmed severe malignancy encasing the entire stomach. Discussion: Triple negative BC can rarely metastasize to the stomach, often mimicking primary gastric malignancy on initial presentation. Clinicians should have a higher index of suspicion for metastases in the setting of previous diagnosis of BC, to not delay potential therapies. Timely EGD biopsies, with useful BC specific markers on IHC staining (CK7 and GATA3), assisted in a rare diagnosis of a metastatic discordant triple negative BC in the stomach. [3565] Figure 1. (A) EGD view of distal esophagus. (B) Ultrathin endoscope view of abnormal stomach mucosa. (C) Ultrathin endoscope view of abnormal stomach mucosa. (D) Rare, poorly differentiated malignant cells -consistent with breast primary -that on IHC stain are positive for CK7 and GATA3. Tumor cells are negative for ER, PR, CDX2, CK20.
Introduction: Double pylorus also termed double-channel pylorus is an endoscopic finding that refers to the presence of a double connection between the gastric antrum and the duodenal bulb. This connection is typically established through the presence of a gastroduodenal fistula. Despite that double pylorus is reported in the literature, its incidence is extremely low and accounts for less than 0.4% of upper endoscopic findings. Herein we report the case of 74 year-old Albanian man who was found to have a double pylorus in the setting of peptic ulcer disease. Case Description/Methods: A 74 year-old man with history of hypertension presented to the emergency room with a few week history of epigastric pain, nausea and vomiting. He denied NSAIDs intake. Vital signs were within normal range. Physical examination revealed epigastric tenderness. Laboratory tests were unremarkable. Abdominal CT scan showed inflammatory changes of the gastric antrum and proximal duodenum (panel A). Findings on upper endoscopy included erythema and edema of the gastric wall, a 7 mm cratered duodenal bulb ulcer in addition to a gastroduodenal fistula that connected the gastric antrum to the proximal duodenum consistent with a double pylorus (panel B). Routine staining of gastric biopsies identified Helicobacter Pylori (HP) organisms. The patient received high dose proton pump inhibitors and Helicobacter Pylori eradication regimen. His symptoms significantly improved and was successfully discharged home after few days of treatment initiation. He was advised to avoid Non-steroidal anti-inflammatory drugs and was scheduled for an outpatient follow-up to document eradication of HP. Discussion: Double pylorus was first described in 1969. It is twice as common in men compared to women. It can be congenital or acquired. Congenital cases are associated with gastric duplication, heterotrophic pancreatic tissue and pancreas divisum. Acquired double pylorus is usually secondary to systemic diseases, gastric malignancy, drugs or Helicobacter Pylori infection that lead to the formation of a fistulous tract between the gastric antrum and the proximal duodenum. Double pylorus can be asymptomatic or manifest as gastrointestinal bleeding or abdominal pain. Treatment includes acid suppression via proton pump inhibitors or H2-Receptor antagonists. Refractory and complicated cases require advanced endoscopic or surgical interventions.[3741] Figure 1. Panel A: CT scan of the abdomen showing inflammatory changes of the gastric antrum and proximal duodenum; Panel B: Upper endoscopy showing a gastroduodenal fistula connecting the gastric antrum to the proximal duodenum consistent with a double pylorus.
Introduction: Helicobacter pylori infection (HPI) has become a worldwide concern due to its associations with intestinal and extraintestinal disease including cancer, autoimmune phenomena, and vitamin deficiencies. HPI has been found to affect Hispanics at higher rates compared with non-Hispanics in the USA. Hispanics comprise most of the patient population at Metropolitan Hospital in New York City. Growing concerns about antibiotic resistance led to the reconciliation of treatment guidelines with the consensus of bismuth quadruple therapy as the first-line treatment, replacing clarithromycin-based triple therapy. We conducted a retrospective study to explore the resistance rate of Helicobacter pylori to triple therapy in patients at Metropolitan Hospital.Objective: To explore the resistance rates of Helicobacter pylori in infected patients treated with clarithromycin-based triple therapy in Metropolitan Hospital over a five-year period.Materials and Methods: Charts of all patients who underwent upper endoscopy during a five-year period were retrospectively reviewed. Overall, 2000 patients were screened for presence of HPI. We included 322 patients with a demonstrated HPI obtained from biopsies taken during upper endoscopy within the study period. Inclusion criteria were patients older than 18 years old with positive HPI who were prescribed therapy. Exclusion criteria were patients with positive HPI who did not receive treatment for the infection and patients without a confirmatory diagnosis of infection. We further reported on three groups based on the implemented therapy. Each treated group was divided into three subgroups based on eradication testing. Treatment compliance was documented. The patient population was demographically characterized by ethnicity, age at diagnosis, body mass index (BMI), and sex.Results: Of the 322 patients included in the study, 258 were Hispanics (80%). The eradication rate among patients treated with selected clarithromycin-based therapies was found to be statistically significant when compared with other HPI therapies. There was no statistically significant difference between the studied group with respect to age, sex, ethnicity, and BMI. In the group of patients with suspected clarithromycin resistance, antimicrobial sensitivity testing was ordered in one case.Discussion: HPI varies with race and ethnicity. Within the USA, the prevalence is lowest among non-Hispanics. Ethnicity and age, sex, and BMI were not factors that impacted treatment outcomes. We found that triple therapy with a proton pump inhibitor, amoxicillin, and clarithromycin (PAC) was used as a firstline treatment, consistently showing a low rate of resistance. The eradication rate among patients treated with PAC was found to be statistically significant when compared with all other therapies. It is significant for the hospitals with limited resources, where initial treatment follows the "test-and-treat" strategy. Quadruple therapy as the first-line treatment raises concerns about medication costs, insurance covera...
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