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Low-grade epilepsy-associated tumors (LEAT) are brain tumors that should be differentiated as a cause of symptomatic epilepsy in children. The most common initial symptom is epileptic seizure, particularly focal seizures. We present a case of LEAT in which an infant presented to our department with convulsive-like seizures that were observed from approximately 3 months of age. At the first visit, growth and development, including head circumference, were appropriate for age. The seizures were atypical, but ictal video electroencephalography showed abnormal waves indicative of left hemispheric epilepsy. The patient subsequently presented with somnolence and poor feeding, and a sudden increase in head circumference and hydrocephalus were observed. Thus, the patient was urgently admitted to the neurosurgery department of our hospital. Brain MRI showed a suspected brain tumor and elective craniotomy was performed. No epileptic seizures were observed postoperatively. When focal epileptic seizures are observed in infancy, a brain tumor should also be considered as a differential diagnosis, and further examination may be warranted.
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Objective: Retrieval is challenging once prophylactic pancreatic stents migrate deep into the pancreatic duct. Herein, we describe a case of successful endoscopic retrieval of a migrated prophylactic pancreatic stent using a basket catheter through a biliary plastic stent pusher tube.Patient: A 71 year-old man was referred to our hospital for removal of a straight-shaped migrated 5-Fr 3-cm prophylactic pancreatic stent with a flap on the duodenal side. There were no subjective symptoms at the time of the hospital visit.Results: During endoscopic retrograde cholangiopancreatography, we inserted an 8.5-Fr plastic biliary stent pusher tube in front of the migrated pancreatic stent. The stent was then grasped using a basket catheter for peroral cholangioscopy through the biliary stent pusher tube. The stent was pulled into the pusher tube and was successfully retrieved from the pancreatic duct. No complications were associated with endoscopic retrograde cholangiopancreatography.Conclusion: Although rare, prophylactic pancreatic duct stent migration after pancreatic duct guidewire placement should be noted. In our case, endoscopic retrieval of a migrated prophylactic pancreatic stent using a basket catheter for peroral cholangioscopy through the biliary plastic stent pusher tube was successful.
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Objective: To describe the case of a patient with intraperitoneal bleeding from the gastroepiploic artery by endoscopic ultrasound who was successfully treated with transcatheter arterial coil embolization.Patient and Methods: An 87-year-old man was referred to our hospital for examination of a gallbladder tumor. Endoscopic ultrasonography was performed using an oblique-view echoendoscope. After the endoscopic ultrasound, the patient went into shock. Computed tomography revealed a huge intraperitoneal hematoma and an aneurysm in the right gastroepiploic artery that were not seen on previous computed tomography images. Thus, urgent catheter angiography was performed, which showed a pseudoaneurysm of the right gastroepiploic artery and extravasation of the contrast medium from the pseudoaneurysm.Results: Transcatheter arterial coil embolization was subsequently performed, and the bleeding stopped. Thereafter, his hemodynamics stabilized and his general condition improved. The patient was discharged 22 days post-treatment with an uneventful course.Conclusion: Observation-only endoscopic ultrasound without invasive procedures can cause intraperitoneal bleeding due to a ruptured splanchnic artery. Thus, endoscopic ultrasonography should be performed more carefully in elderly patients.
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An 86-year-old man diagnosed with distal cholangiocarcinoma was treated with uncovered biliary metal stent placement. The metal stent was occluded due to growth of the tumor into the stent. Although he underwent placement of two additional plastic stents in the metal stent, the plastic stents were also rapidly occluded. He was admitted and underwent transpapillary exchange of the plastic stents. Five days later, endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) was performed using a plastic stent. The patient had no recurrence of cholangitis thereafter and was discharged 42 days after EUS-HGS.
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An 83-year-old woman who vomited blood was taken to our hospital by ambulance. She was taking oral ticlopidine for chronic arterial occlusion of the lower extremities. Emergency upper gastrointestinal endoscopy revealed bleeding from a gastric polyp. Following endoscopic mucosal resection, the clinical course was uneventful and she was discharged 7 days after admission. Histopathology revealed that the resected gastric polyp was a hyperplastic polyp with no malignant findings.
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Objectives: Duodenal perforation as a complication of endoscopic ultrasound-guided fine needle aspiration may progress to acute peritonitis and septic shock. Open surgery, the standard treatment, can be avoided by performing closure during endoscopy using endoscopic clips.Patient: A 77-year-old woman was referred to our hospital with salivary gland swelling. She had elevated hepatobiliary enzymes and jaundice. Computed tomography (CT) revealed pancreatic head swelling and bile duct dilation. Endoscopic ultrasonography revealed a hypoechoic mass in the pancreatic head. The pancreatic head mass was punctured twice using a 22-gauge Franchine-type puncture needle at the duodenal bulb. The endoscope was advanced to the descending part of the duodenum, and part of the superior duodenal angle was perforated (diameter approximately 15 mm) with the endoscope. The duodenal mucosa around the perforation was immediately closed using endoscopic clips.Results: Abdominal CT showed gas in the peritoneal and retroperitoneal spaces. The patient experienced abdominal pain and fever and was treated with fasting and antibiotics. The gas gradually decreased, symptoms improved, and she was discharged 18 days after the perforation. Histopathologically, the pancreatic tissue was consistent as autoimmune pancreatitis.Conclusion: Endoscopic closure using endoscopic clips may be a better therapeutic option for duodenal perforation caused by endoscopy.
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An 85-year-old man who developed sudden neck pain after ingesting walnuts visited our hospital. Computed tomography showed food impaction in the cervical esophagus. Upper gastrointestinal endoscopy revealed a walnut half that was not chewed at all in the cervical esophagus. The walnut half was pushed into the stomach with the endoscope and removed using a retrieval net. No strictures, neoplastic lesions, or ulcerations were found in the esophagus. The neck pain improved after the procedure.
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A 77-year-old woman was referred to our hospital because of general malaise and appetite loss for 3 months. Contrast-enhanced computed tomography showed a gallbladder tumor and multiple tumors in the liver. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was performed for the gallbladder tumor. Histopathologically, the tumor was diagnosed as poorly differentiated adenocarcinoma. There were no complications of EUS-FNA. While waiting for the histopathological results of EUS-FNA, her appetite loss gradually became severe, so she declined systemic chemotherapy. She was discharged from the hospital 15 days after EUS-FNA. EUS-FNA for gallbladder lesions is useful when pathological diagnosis is required.
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An 86-year-old man was diagnosed with obstructive jaundice due to extrahepatic bile duct tumor. Percutaneous transhepatic biliary drainage (PTBD) was performed following failed transpapillary biliary drainage. The next day, a biliary metal stent was placed by rendezvous endoscopic retrograde cholangiopancreatography (ERCP) and a tube was also placed via the PTBD route. Two days later, a computed tomography scan showed emphysema in the abdominal wall where the PTBD tube was inserted. He was diagnosed with cellulitis. The PTBD tube was removed and incisional drainage was performed. Klebsiella oxytoca was cultured from the pus. He subsequently improved and was discharged 22 days after the rendezvous ERCP.
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An 87-year-old woman developed anorexia and jaundice. Contrast-enhanced computed tomography revealed a tumor of the duodenal papillae. Percutaneous transhepatic biliary drainage was performed instead of transpapillary biliary drainage due to stenosis of the duodenum. She complained of pain at the insertion site of the percutaneous drainage tube, and endoscopic ultrasonography-guided choledochoduodenostomy (EUS-CDS) was performed. A duodenal stent was placed 3 days later. The percutaneous biliary drainage tube was removed, and her recovery was uneventful. She was subsequently discharged. No further treatment for biliary or gastrointestinal tract system was needed. She died 146 days after EUS-CDS.
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Case 1: An 82-year-old man presented with fever and right hypochondralgia, and he was diagnosed with acute cholecystitis. Percutaneous transhepatic gallbladder drainage (PTGBD) was performed on the day of admission. On hospital day 16, endoscopic ultrasonography-guided gallbladder drainage (EUS-GBD) was performed. The percutaneous drainage tube was removed on hospital day 22. Recovery was uneventful, and he was discharged on day 35. Case 2: A 72-yearold woman presented with fever and right hypochondralgia, and she was diagnosed with acute cholecystitis. PTGBD was performed the next day, and her general condition improved thereafter. She was diagnosed as having rectal cancer with liver metastasis, and we determined that invasion evaluated at cholecystectomy would possibly shorten survival time. We performed EUS-GBD on hospital day 10. The percutaneous drainage tube was removed on day 18 and her recovery was uneventful. She was discharged on day 39.
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Objectives: Rectus sheath hematoma (RSH) can result from bleeding into the rectus abdominis muscle or a direct muscular tear; nontraumatic spontaneous RSH is a rare condition. Here, we report a case of spontaneous RSH associated with warfarin administration for the treatment of chronic thromboembolic pulmonary hypertension (CTEPH).Patient: An 87-year-old woman was referred to our hospital because of abdominal pain, nausea, and vomiting for 3 days. She was receiving warfarin for treating CTEPH. She had a bulging and hard lower abdomen with ecchymosis. Moreover, the bulging portion was highly tender, and a positive Carnett’s sign was also observed. She reported no history of abdominal trauma. Abdominal computed tomography (CT) scan revealed right RSH.Results: She was diagnosed with spontaneous RSH and admitted to our hospital. Warfarin was antagonized with an intravenous injection of vitamin K; hemostatic agents were intravenously administered. Gradually, her abdominal pain improved. She was finally discharged 12 days after the admission. Abdominal CT scan performed 17 days after the discharge revealed a reduction in the size of RSH.Conclusion: Despite not having a history of trauma, it is necessary to consider the possibility of RSH for patients receiving warfarin and complaining of abdominal pain.
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Objective: This study aimed to assess the efficacy and safety of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in patients with an Eastern Cooperative Oncology Group performance status (ECOG-PS) score of 3 or 4.Patients and Methods: We reviewed the data of 287 patients with native papillae who underwent therapeutic ERCP for biliary disease at our hospital between October 2016 and October 2018. The patients were divided into two groups; those with an ECOG-PS score of 3 or 4 (group A; n=78) and those with an ECOG-PS score of 0–2 (group B; n=209).Results: The rate of technical success was not significantly different between the two groups (95% versus 89%, P=0.13). Although the occurrence rate of overall adverse events (10% versus 11%, P=0.95) was not significantly different between the groups, the occurrence rates of aspiration pneumonia (3.8% versus 0%, P=0.0044) and heart failure (2.6% versus 0%, P=0.020) were significantly higher in group A.Conclusion: The rates of technical success and overall adverse events did not significantly differ between patients with an ECOG-PS score of 3 or 4 and those with a score of 0–2; however, aspiration pneumonia and heart failure were more likely to occur among patients with an ECOG-PS score of 3 or 4.
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A man in his 50's was referred to our hospital for hematemesis and hematochezia. He had previously presented to another hospital for ulcerative colitis that was in remission with a prescription of 11 mg prednisolone and adalimumab. He also had a history of partial gastrectomy. Although detailed information on the gastrectomy was unavailable upon arrival at our hospital, contrast-enhanced computed tomography scan suggested that he had undergone a distal gastrectomy with Billroth II reconstruction. Emergency upper gastrointestinal endoscopy revealed an ulcer with an exposed blood vessel at the Braun anastomosis; thus, clipping hemostasis was performed. However, hematemesis occurred 3 days later, and another emergency upper gastrointestinal endoscopy revealed that the clips at the Braun anastomosis had deviated from the original position; therefore, clipping hemostasis was repeated to stop the bleeding from the exposed blood vessels. Subsequently, he was provided intravenous hyperalimentation, after which he resumed oral intake 14 days after the second clipping. No bleeding was observed after the second clipping, and he was discharged 22 days after admission.
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A man in his 80’s presented with sudden onset chest pain in the outpatient waiting room at our hospital and was diagnosed with acute myocardial infarction. Emergency coronary angiography was performed, and a drug-eluting stent was placed in the occluded right coronary artery. After the procedure, the patient developed high-grade fever (40°) with chills. Computed tomography revealed retroperitoneal and iliopsoas abscesses. The patient’s condition did not improve with the administration of antibiotics, so a drainage procedure was deemed necessary. Because of the stent, he was prescribed dual antiplatelet therapy (DAPT) with aspirin and prasugrel. Two days after stent placement, percutaneous abscess drainage was performed with the patient continuing DAPT. No bleeding occurred when a drainage tube was placed. The tube was withdrawn 19 days after insertion. He was then discharged 11 days after removal of the tube.