A Rare Case of Juvenile Polyposis Syndrome Mimicking Ménétrier's Disease.

There is a wide differential diagnosis within polyposis syndromes. Our case represents an interesting and diagnostically challenging diagnosis involving a 41-year-old male who presented with an incidental gastric mass on imaging and a colonic mass seen on colonoscopy. Following multiple endoscopic evaluations, histological analysis, and genetic testing, the patient was ultimately diagnosed with juvenile polyposis syndrome (JPS)/hereditary hemorrhagic telangiectasia (HHT) despite the initial suspicion for Ménétrier's disease. His disease course was complicated by an acute upper extremity thrombus and diagnosis of colorectal carcinoma. This case highlights the importance of a thorough evaluation when polyposis syndromes are suspected. Prompt and accurate diagnosis can aid in the treatment, surveillance, and prevention of colorectal carcinoma.

Gastric Splenosis Mimicking Gastrointestinal Stromal Tumor.

Translocation of splenic tissue in patients after traumatic spleen injury or splenectomy is called splenosis. Gastric splenosis is a rare presentation that can be mistaken for gastrointestinal stromal tumor (GIST). Patients are usually asymptomatic and do not require surgical intervention. In this report, we present a case of a 68-year-old male patient with a previous history of surgical splenectomy after traumatic splenic rupture, who underwent routine upper endoscopy for the evaluation of dysphagia. An endoscopic exam of the stomach revealed an incidental finding of a submucosal gastric nodule. On endoscopic ultrasound exam, the lesion was found to be suggestive of GIST originating from layer 4. A core biopsy was obtained from the nodule, which was consistent with gastric splenosis. The differentiation of gastric splenosis from other gastric lesions such as GIST is important since asymptomatic patients with gastric splenosis do not need to undergo surveillance or surgical resection. It should be suspected especially in patients with a history of splenectomy or splenic rupture. Endoscopic ultrasound (EUS)-guided core biopsy can help confirm the diagnosis and differentiate the condition from GIST.

Novel case of percutaneous access of afferent limb of Roux-en-Y hepaticojejunostomy for biliary decompression and jejunoplasty in a patient with primary sclerosing cholangitis.

Primary sclerosing cholangitis is a rare condition characterized by multifocal fibrotic bile duct strictures and progressive liver disease. Due to its recurrence even after liver transplantation, an alternative surgical procedure, the Roux-en-Y hepaticojejunostomy, is practiced with positive outcomes. We present a case of a 55-year-old female with history of primary sclerosing cholangitis and Roux-en-Y hepaticojejunostomy approximately 25 years ago who presented to the emergency department with acute cholangitis. Computed tomography of the abdomen revealed a dilated loop of small bowel in the right upper quadrant and mid-abdomen with normal bile duct caliber. Interventional radiology was consulted for percutaneous biliary and Roux limb decompression. Ultrasound was utilized to identify and percutaneously access the dilated afferent jejunal limb. With the help of a T-fastener, the jejunal loop was tacked against the anterior abdominal wall and the system was successfully decompressed with a drain left in place. On follow-up, delayed contrast transit through the Roux limb and a stricture in the native jejunum distal to the anastomosis was identified. Hampering of the downstream flow of bile was noted and this was determined to be the likely cause of the initial episode of cholangitis. The strictured bowel segment was balloon-dilated by interventional radiology. Repeat injection of contrast revealed significant improvement in the caliber of the stenotic segment. At 3 weeks' postprocedure, a follow-up enteroscopy of the bowel was performed through the same percutaneous access site. Using this technique, the patient avoided a major invasive surgical procedure.

Patient Satisfaction and Understanding of Moderate Sedation During Endoscopy.

Millions of endoscopic procedures are performed in the US every year and the use of procedural sedation analgesia (PSA) is increasing with more procedures being performed outside the operating theater and gaining popularity due to reduced costs. Patients having endoscopic procedures usually expect that they would be deeply sedated during the procedure despite verbal counseling during pre-procedure clinic visits and are often dissatisfied with procedural awareness and discomfort. In order to better educate patients, written supplementary reading material was provided to the patients, which stated a clear goal of comfort during the procedure rather than deep sedation. The results showed that the written supplementary material did not improve the patient's understanding or remembrance of being counseled about moderate sedation. We emphasize that there is no substitute for a physician's repetitive verbal counseling.

Rare Complication of Interventional Radiology-guided Arterial Embolization of the Gastroduodenal Artery in the Setting of Acute Gastrointestinal Bleed: Migrated Coils in the Duodenum.

A 91-year-old male presented to the emergency room with hemodynamically significant upper gastrointestinal bleeding. The patient underwent an esophagogastroduodenoscopy (EGD), which showed frank blood in the duodenum interfering with the visualization. Hence, the patient underwent urgent interventional radiology (IR)-guided arteriogram and embolization. An EGD done 48 hours later showed a giant, non-bleeding, cratered duodenal ulcer with a visible vessel and vascular coils partially protruding into the duodenal bulb lumen. The patient had no evidence of bleeding post embolization. The patient presented three months later with abdominal pain. Computed tomography (CT) abdomen showed multiple liver abscesses. IR-guided drainage of abscesses was performed, and the culture grew Streptococcus intermedius. Magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and barium enema were unremarkable. The patient was treated with a prolonged course of intravenous (IV) antibiotics and recovered without any further issues. IR guided arterial embolization can be lifesaving in cases where GI bleeding cannot be controlled endoscopically, however, it can lead to serious complications, including endovascular coil migration into the gastrointestinal (GI) lumen causing infection and re-bleeding. Endovascular coil migration can occur immediately or several years later, which can result in fatal bleeding and infection. The best approach to prevent and manage migrated endovascular coils in the GI lumen remains unclear.

Bouveret syndrome as a rare cause of gastric outlet obstruction.

Biliary-enteric fistula is a rare complication of cholelithiasis that can lead to gallstone ileus. Gallstone impaction in the duodenum and pylorus is extremely rare and can lead to gastric outlet obstruction, a condition known as Bouveret syndrome. Bouveret syndrome needs to be diagnosed and managed in a timely fashion, as it has a high mortality rate. We describe a case of an elderly patient who presented with Bouveret syndrome secondary to impaction of the biliary calculus in the first part of duodenum.

Role of Endoscopic Resection Versus Surgical Resection in Management of Malignant Colon Polyps: a National Cancer Database Analysis.

BACKGROUND: Endoscopic resection (polypectomy) or surgery, are the main approaches in management of malignant colon polyps. There are very few large population-based studies comparing outcomes between the two. METHODS: Using the National Cancer Database, we identified patients ≥ 18 years with the first diagnosis of T1N0M0 malignant polyp from 2004 to 2015. Patients with a positive resection margin were excluded. Outcomes were compared between those who had surgery versus those who had polypectomy. Overall survival was compared using Kaplan-Meier curves. Multivariate Cox proportional hazards analysis was performed to generate hazard ratios, adjusted for patient, demographic, and tumor factors. RESULTS: A total of 31,062 patients met the inclusion criteria, out of which 2593 (8.3%) underwent polypectomy alone and 28,469 (91.7%) had surgery. Overall survival was significantly better in the surgical group compared with the polypectomy group. One-year and 5-year survival for surgery were 95.8% and 86.1% respectively compared with 94.2% and 80.6% for polypectomy (p < .0001). Hazard ratio for surgery after adjusting for various clinical-, demographic-, and tumor-level factors was 0.53 (p < .0001). CONCLUSION: Our study is the largest population-based analysis of patients with T1N0M0 malignant colon polyps. Overall survival was higher in patients who underwent surgery compared with polypectomy. This remained consistent even after adjusting for multiple patient and tumor factors between the two groups.

Attitudes and perceptions about prenatal diagnosis and induced abortion among adults of Pakistani population.

OBJECTIVES: Perception and attitude regarding prenatal screening and induced abortion vary across different populations. This study assesses the attitudes and perceptions regarding prenatal screening and induced abortion among Pakistani adults. METHODS: We conducted a cross-sectional study among adults (18+) coming to the Aga Khan University Hospital, a private tertiary care hospital in Karachi, Pakistan. RESULTS: Majority (65%) of the study population had knowledge about prenatal screening and it was acceptable to most (85.5%) of them. Significant proportion had high acceptance for induced abortion (23%) of a fetus that has serious congenital anomalies. On the other hand, 15% were unwilling to consider termination of pregnancy (TOP) in any circumstances. Women had more favorable attitude toward induced abortion. Most of the respondents (63%) were in favor of abortion if fetal death was imminent as a result of a congenital abnormality. Majority wanted mutual consultation of husband and wife for making decision regarding induced abortion (84%). CONCLUSION: There was a considerable discord in opinion about abortion in the study population. Health care providers should involve both parents in making decisions about abortions and counsel them adequately about congenital disorders.