A Novel Approach to Percutaneous Endoscopic Gastrostomy Tube Replacement: Can You Save the Site?

Inadvertent removal or dislodgement is the most commonly encountered complication in patients with percutaneous endoscopic gastrostomy (PEG) tube. Once the gastrocutaneous fistula is formed, bedside tube replacement can be performed at the same site, within 24 hours of dislodgement. Usually, after this timeframe, the tract closes; hence, it is recommended to perform a replacement at a different site. We report a case of a 52-year-old female who presented after 24 hours of inadvertent PEG tube removal. A replacement was performed successfully via endoscopy at the same site of the erstwhile PEG tube, although it appeared to be closed.

Incidence of Thrombotic Events and Outcomes in COVID-19 Patients Admitted to Intensive Care Units.

Introduction While coronavirus disease 2019 (COVID-19) mostly causes respiratory illnesses, emerging evidence has shown that patients with severe COVID-19 can develop complications like venous thromboembolism (VTE) and arterial thrombosis as well. The incidence of thrombosis among critically ill patients in the literature has been highly variable, ranging from 25 to 69%. Similarly, reported mortality among critically ill patients has been highly variable too, and it has ranged from 30 to 97%. In this study, we analyzed data from a large database to address the incidence, the risk factors leading to thrombotic complications, and mortality rates among COVID-19 patients. Material and methods Data were obtained from TriNetX (TriNetX, Inc., Cambridge, MA), a multinational clinical research platform that collects medical records from 42 healthcare organizations (HCOs). All nominal data were compared using the chi-squared test. Alpha of <0.05 was considered statistically significant. We used Benjamini-Hochberg correction with a false discovery rate of 0.1 to correct for multiple comparisons. Results We identified 18,652 COVID-19-positive patients, with a median age of 50.7 years [interquartile range (IQR): 31.8-69.6]; among them, 51.8% (9,672) were males and 48.2% (8,951) were females. Of these patients, 630 [3.37%; median age: 61 years (IQR: 44.9-77.1)] were critically ill, requiring intensive care unit (ICU) care within one month of their diagnosis. Men were over-represented among the ICU patients when compared to women (3.7% vs 3%, p=0.009, Χ2=6.66). African Americans were over-represented among the ICU patients when compared to Caucasians (8.5% vs 4%, p<0.0001, Χ2=76.65). Older patients, i.e., 65 years and older, were over-represented in the ICU compared to patients aged 18-64 years (6.8% vs 2.5%, p<0.0001, Χ2=121.43). The cumulative incidence of thrombotic events in the ICU population was 20.4% (129/630). Thrombotic events were significantly more common in patients who were 65 years and older when compared to patients in the age group of 18-64 years (24.6% vs 17.31%, p=0.02, Χ2=5.38). Mortality among ICU patients was higher in those who were 65 years and older when compared to the age group of 18-64 years (31.9% vs 17.3% p=0.0003, Χ2=18.41). The overall mortality in the study population was higher in patients who were 65 years and older when compared to patients aged 18-64 years (18.55% vs 1.4%, p<0.0001, Χ2=1915). Conclusions Among COVID-19 patients, men, African Americans, and people who are 65 years and older are more likely to have severe disease and require ICU level of care. Patients who are 65 years and older are more likely to have thrombotic events, myocardial infarction (MI), and stroke. Overall mortality and ICU mortality are higher among COVID-19 patients who are 65 years and older.

Roth Net-Assisted Endoscopic-Guided Manometry Catheter Placement.

High-resolution esophageal manometry (HRM) has become the gold standard to diagnose esophageal motility disorders. Usually, this procedure is performed by introducing the catheter, which has pressure sensors, into the esophagus and proximal stomach via the nares. Repeated coiling of the catheter and inability to pass through the gastroesophageal junction (GEJ) are common challenges encountered. Endoscopy-guided placement of the catheter can overcome these difficulties. However, sometimes even with the use of endoscopy, it is difficult to advance catheter due to anatomical variants. The extreme fragility of the catheter and sensors and the high cost of this reusable device precludes the use of biopsy forceps or snare to advance the catheter. There is no literature on using accessories during endoscopy in case of difficult placement under direct visualization. We report a unique case of using Roth Net via the suction channel to advance esophageal manometry catheter into the stomach by using endoscopy.

Spontaneous Rupture of Fibrolamellar Variant Hepatocellular Carcinoma.

Fibrolamellar hepatocellular carcinoma (FL-HCC) is a unique variant of hepatocellular carcinoma. The majority of cases present with nonspecific symptoms like vague abdominal pain, weight loss and fatigue. Ruptured FL-HCC occurs rarely and mortality in the acute phase is very high. We report a rare case of a ruptured FL-HCC successfully managed with transarterial embolization for hemostasis. A 37-year-old male previously in good health presented with a severe, sharp epigastric pain that started 1 h prior to the presentation. He denied trauma, fever, nausea, vomiting, or diarrhea. Tenderness in the epigastrium was noted, with no palpable masses, guarding or rigidity. His blood pressure and pulse were 159/105 mm Hg and 105 beats/min. Platelets and coagulation parameters were within normal limits; transaminases were elevated. Abdominal computed tomography (CT) scan with contrast revealed an 8 cm lobulated mass with central hypodensity in the left hepatic lobe with perilesional blood and free pelvic fluid, indicating tumor rupture. CT angiography showed tumor neovascularization from a branch of the left hepatic artery which was embolized using transarterial gelfoam. Liver magnetic resonance imaging (MRI) and biopsy were consistent with fibrolamellar variant hepatocellular carcinoma. After 4 days, as the symptoms resolved, and the lab results were stable, patient was discharged and underwent a left hepatectomy 3 weeks later. FL-HCC occurs commonly in the left lobe of a young and non-cirrhotic liver. Typically, cross sectional imaging reveals a lobulated mass with well-defined margins, areas of hypervascularity and a central calcified scar. Histologic appearance is characterized by eosinophilic polygonal shaped cells separated by lamellar fibrosis. Surgical resection is the treatment of choice with better outcome when compared to conventional HCC. Disease recurrence after complete surgical resection is however high in the first 5 years. Tumors > 5 cm in size are at high risk for rupture with high mortality and recurrence rates secondary to significant spillage of tumor. While an emergency hepatectomy is preferred in unstable patients, those that are hemodynamically stable can undergo radiologic transarterial embolization for hemostasis followed by staged hepatectomy.

Successful Treatment of Hepatitis C Virus by Ledipasvir/Sofosbuvir in a Cirrhotic Patient with Sickle Cell Disease and Thalassemia Minor.

Around 8% of patients diagnosed with sickle cell disease (SCD) are hepatitis C virus (HCV) carriers. Previously, HCV treatment was seldom considered in SCD patients, as the ribavirin-induced hemolysis and interferon-induced cytopenias could lead to more profound anemia. Nowadays, several oral direct-acting antiviral drugs have been developed and approved by the FDA for hepatitis C treatment. While direct-acting antivirals mitigate many of these risks, their safety and efficacy in SCD patients remains insufficiently explored. Here, we report on successfully treating HCV with ledipasvir/sofosbuvir in a compensated cirrhotic patient with SCD and thalassemia minor.

Solitary Polypoid Angiodysplastic Lesion Mimicking a Tumor in the Jejunum.

Small bowel bleeding should be considered in patients with overt or occult gastrointestinal hemorrhage after normal upper and lower endoscopic examination. Angiodysplasia appearing as multiple flat vascular tufts is the most common cause of small bowel bleeding in patients over 40 years old. Polypoid angiodysplasia, however, is extremely rare. This report illustrates a unique case of solitary polypoid angiodysplasia in the jejunum of an adult with chronic kidney disease, who presented with an occult gastrointestinal bleed. The angiodysplasia mimicked tumorous growth, potentially indicative of malignant neoplasm. The patient underwent surgical resection and was histologically diagnosed as having angiodysplasia.