Gastrointestinal Endoscopy
Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie in Bailey & Love's Short Practice of Surgery, 2018
OGD is the most commonly performed endoscopic procedure. Excellent visualisation of the oesophagus, gastrooesoph- ageal junction, stomach, duodenal bulb and second part of the duodenum can be obtained (Figure 15.2). Retroversion of the gastroscope in the stomach is essential to obtain complete views of the gastric cardia and fundus (Figure 15.2). Traditional forward-viewing endoscopes do not adequately visualise the ampulla, and a side-viewing scope should be used if this is essential. Likewise, although it is possible to reach the third part of the duodenum with a standard 120 cm instrument, a longer enteroscope is required if views beyond the ligament of Treitz are required. In addition to clear mucosal views, diagnostic endoscopy allows mucosal biopsies to be taken, which may either undergo processing for histological examination or be used for near-patient detection of Helicobacter pylori infection using a commercial urease-based kit. In addition, brushings may be taken for cytology and aspirates for microbiological culture.
Celiac Disease
John F. Pohl, Christopher Jolley, Daniel Gelfond in Pediatric Gastroenterology, 2014
Current North American guidelines require duodenal biopsies, while on a gluten-containing diet, to make the diagnosis of celiac disease. The European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN), on the other hand, has recently revised their guidelines to allow omission of duodenal biopsies in the symptomatic pediatric patient with a tTG IgA greater than 10 times the upper limit of normal, provided they are EMA and HLA positive. Those not meeting these conditions must still demonstrate the histologic features indicative of celiac disease in order for diagnosis. As the characteristic histologic lesions may be patchy, a minimum of four biopsies should be obtained from the second or more distal duodenum and additional biopsies should be obtained from the duodenal bulb, as isolated disease of the bulb has been well demonstrated and bypassing the bulb may lead to a missed diagnosis in up to 10% of patients.
Mixed Cavernous Hemangioma-Lymphangioma of the Gastroesophageal Junction
Wickii T. Vigneswaran in Thoracic Surgery, 2019
A 61-year-old Hispanic man with a history of gastroesophageal reflux disease and hypertension presented with increasing fatigue. He denied any history of unintentional weight loss, hematochezia, or hematemesis. He did not drink alcohol or use tobacco and had a maternal history of esophageal cancer. Physical exam revealed a well-nourished man with mild epigastric tenderness. Routine bloodwork revealed anemia with a hemoglobin of 12 g/dL. He was referred to gastroenterology for an endoscopy. His colonoscopy was normal, but upper endoscopy demonstrated a soft, bluish polypoid lesion 25 cm from the incisors extending submucosally to the gastroesophageal junction (Figure 43.1). The stomach and duodenal bulb appeared normal. Biopsy was not performed due to its hypervascular appearance. Positron-emission tomography-computed tomography (PET-CT) demonstrated esophageal thickening with a low-attenuating 12 × 11 × 8 cm mass extending from the carina to gastroesophageal junction with areas of increased metabolic activity ranging from SUV 2.5 to 7.6 (Figure 43.2). No axillary, mediastinal, or hilar lymphadenopathy was identified. Endoscopic ultrasound further characterized the mass as being nearly circumferential and heterogeneous in composition with cystic and hypervascular areas (Figure 43.3).
Duodenal bulb obstruction caused by a gallstone (Bouveret syndrome) successfully treated with endoscopic measures
Published in Baylor University Medical Center Proceedings, 2020
Gilles Jadd Hoilat, Vanessa Sostre, Judie N. Hoilat, Ceren Durer, Seren Durer, Gowthami Kanagalingam, Divey Manocha
On postoperative day 1, there was biliary drainage in the Blake drain. A hepatobiliary iminodiacetic acid scan came back negative and a subsequent computed tomography scan showed no definite evidence of peripheral contrast enhancement suggestive of postsurgical fluid with air. Days later, there was still concern for high output from the drain and she was evaluated by the gastroenterology service for endoscopic retrograde cholangiopancreatography (ERCP). An endoscopic procedure showed that the duodenal bulb was impacted with a large 3 cm stone (Figure 1a, 1b), causing gastric outlet obstruction. The impacted stone was successfully removed with a snare (Figure 1c, 1d). A small bile leak was found at the cystic duct stump; a 10 mm size biliary sphincterotomy was performed and one plastic stent was placed in the common bile duct with bile drainage. Upon review of previous imaging and the surgical report and discussion with the surgical team, there was no evidence of any sort of fistula that would normally lead to the gastric outlet obstruction. After ERCP, the patient experienced marked improvement of her symptoms. She was tolerating her diet and subsequently was discharged home.
Crohn’s disease exclusion diet in children with Crohn’s disease: a case series
Published in Current Medical Research and Opinion, 2021
Luca Scarallo, Elena Banci, Valentina Pierattini, Paolo Lionetti
A 12-year-old boy with unremarkable past medical history presented to our outpatient clinic with a 3-month history of epigastric pain, reduced appetite and weight loss. Prior to our center’s referral, the patient was evaluated at a secondary-level pediatric center and a 2-week empirical trial with a proton pump inhibitor was attempted, without symptoms alleviation. Physical examination was unremarkable except for the presence of 2 perianal skin tags. His blood tests revealed a slight increase of C-reactive protein (CRP, 1.15 mg/dL), with normal erythrocyte sedimentation rate (ESR); and fecal calprotectin was elevated at 500 microg/g. Hemoglobin was 12.9 g/dL, albumin and transaminases were in the normal range with a pediatric Crohn’s disease activity index (PCDAI) of 20. Bowel ultrasound scan showed no abnormal bowel thickenings. Esophagogastroduodenoscopy (EGD) showed aphthous ulcers in the duodenal bulb but was otherwise normal. Ileo-colonoscopy revealed aphthous ulcers in the terminal ileum, cecum, ascending and descending colon. Biopsies collected during endoscopies confirmed chronic inflammation with mucosal architecture disruption, confirming diagnosis of CD. A magnetic resonance enterography (MRE) revealed multiple enhancement with only limited thickening in the terminal ileum and in the upper digestive tract distally to Treitz’ ligament. No strictures or fistulas were observed (Paris Classification: A1b, L3-L4a,B1,G1, P1)16.
Resolution of a hepatoduodenal fistula after nivolumab treatment in a patient with hepatocellular carcinoma: challenges in immunotherapy
Published in Acta Clinica Belgica, 2022
Thomas De Somer, Erik Vanderstraeten, Vincent Bouderez, Els Monsaert, Christophe Van Steenkiste
Systemic treatment with sorafenib was started. However, the tolerance for sorafenib was poor. The patient experienced excessive weight loss, had a pronounced anorexia and diarrhea and his WHO performance status deteriorated to 3 to 4. The AFP-level initially declined to 800,6 µg/l after 1 month of treatment with sorafenib, but started to gradually increase afterwards. Radiographic re-evaluation after 3 months of treatment with sorafenib showed stable disease on contrast enhanced abdominal CT. However, there was a new finding of air inclusions in the largest lesion in the left liver lobe, which appeared to be connected to the duodenum. The presence of a large fistula in the duodenal bulb was confirmed by gastroscopy (Figure 2). A percutaneous endoscopic gastrostomy with jejunal extension was placed for enteral nutrition. Treatment with sorafenib was discontinued and the patient was evaluated for second line treatment with nivolumab by compassionate use, based on the data of the phase I/II studies available at that time.