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Endoscopic removal of a bullet after mediastinum gunshot injury
At the Focal Point
Commentary Although first described more than a century ago, by Hellstrom in 1906, small intestinal lipomatosis remains a rare condition. Isolated lipomas are much more frequently encountered and, in the small intestine, are most common in the ileum. Lipomatosis affects both genders equally and typically occurs after the fourth decade of life. The lipomas in this condition are usually located in the submucosa but may extend through the bowel wall and into the serosal or mesenteric fat. Lipomas usually are silent, but they may ulcerate and bleed, or they may cause colicky abdominal pain because of intussusception. Jejunal lipomatosis has been reported in association with jejunal diverticulosis, ostensibly due to involvement and attenuation of the muscularis propria. CT scanning or CT enterography is the preferred diagnostic test for intestinal lipomatosis, although capsule endoscopy also can play a valuable role in demonstrating the lipomas. If the lipoma is within reach of the endoscope, a biopsy forceps may be used in several ways to prove the diagnosis. Before biopsy of the putative lipoma, however, the diagnosis might be suspected because of blood vessels that may be seen coursing over the lesion’s surface or an orange-red surface that changes to a more yellow color toward the base of the lesion. As the lesion is probed with a closed biopsy forceps, it indents and then springs back to its previous shape when the forceps is withdrawn: the so-called “pillow sign.” Immediately before the biopsy specimen is taken, the mucosa may be grasped with the forceps and pulled up: the so-called “tenting sign.” Upon biopsy, one may evoke the “naked fat sign,” a finding pathognomonic for lipoma during which fat spills out of the lesion after the biopsy. St Jerome said a fat stomach never breeds fine thoughts. Times have changed, and besides the insensitivity of the comment, I am sure he was referring to the abdomen, not the stomach, and that he had never heard of lipid islands in the stomach or gastrointestinal lipomatosis. Lawrence J. Brandt, MD Associate Editor for Focal Points
Endoscopic removal of a bullet after mediastinum gunshot injury
A 39-year-old policeman was admitted to our emergency department with a thoracic gunshot injury. His only symptom was local pain, without dyspnea, hemoptysis, or hematemesis. On physical examination, a bullet entry wound was seen in the left midclavicular line, and www.giejournal.org
no exit wound or subcutaneous emphysema was identified. Angiotomography showed the bullet lodged at the T1-T2 level, without vascular lesions. An esophagogram revealed the bullet in the upper mediastinum, causing deviation of the esophagus without extravasaVolume 77, No. 6 : 2013 GASTROINTESTINAL ENDOSCOPY 955
At the Focal Point
tion of contrast medium. Upper endoscopy demonstrated an elevated area with a small fistulous orifice (A, arrow). Once the patient was asymptomatic, conservative treatment was adopted. After nasoenteral feeding for 5 days, an oral diet was introduced with good acceptance. Weekly serial endoscopies demonstrated progressive migration of the bullet to the esophageal lumen (B). Twenty-seven days after the trauma, the bullet was removed with alligator forceps. An orifice with adjacent edema was noted at the impact site of the bullet. (C). One week later, the endoscopic study revealed healing of the bullet track and regenerating mucosa adjacent to the site of the previous fistula (D). The patient remained asymptomatic during a 6-month follow-up period.
DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Cristiane Kibune Nagasako, MD, MSc, Ciro Garcia Montes, MD, PhD, Endoscopy Unit of Gastrocentro, Luiz Roberto Lopes, MD, PhD, Department of Surgery, Marina da Silveira Bossi, MD, Endoscopy Unit of Gastrocentro, Maria Aparecida Mesquita, MD, PhD, Gastroenterology Division, Faculty of Medical Sciences, State University of Campinas, Campinas, Brazil http://dx.doi.org/10.1016/j.gie.2013.01.038
Commentary I gotta say this is one of my favorite Focal Points of all time. But without high-tech imagery, obscure once-in-a-lifetime diagnoses, and cutting-edge, high-risk endoscopic solutions—what makes it so cool? Because it beautifully demonstrates both the principles of primum non nocere and cura te ipsum (cure yourself). What drives the microcurrents that wend wayward foreign bodies to the nearest exit (in the case of a splinter, to the outside world; in this case, to the esophageal lumen), and how do they know in what direction to flow? This migratory phenomenon is just one of the wonderments the body does really well; add it to the list that includes hepatic lobar regeneration and about a million others. The authors were prudent to let nature take her course; the close endoscopic surveillance and well-timed armament recovery mission prevented yet more trouble for this remarkably lucky cop. David Robbins, MD, MSc Assistant Editor for Focal Points
Total necrosis of rapid growing hilar cholangiocarcinoma An 81-year-old woman with cryptogenic liver cirrhosis presented with right upper quadrant pain and pruritus. A complete blood cell count showed a hemoglobin of 11.8 g/dL (normal range, 12.0-16.0 g/dL), white blood cell count of 3340 cells/L (normal range, 4000-10,000 cells/ L), and a platelet count of 83,000/L (normal range, 150,000-400,000/L). Liver biochemical tests revealed aspartate aminotransferase of 51 IU/L (normal range, 0-31 IU/L), alanine aminotransferase of 55 IU/L (normal range, 0-31 IU/L), alkaline phosphatase of 179 IU/L (normal range, 39-117 IU/L), and a total bilirubin of 7.3 mg/dL (normal range, 0.2-1.3 mg/dL). A 2-cm moderately attenuated nodular mass at the hilum, not seen on a CT 3 months previously, was noted on abdominal CT (A, arrow). A nasobiliary catheter was inserted for decompression of the bile duct. Fluid cytology showed a few syncytial clusters of malignant columnar cells with prominent nucleoli and intracytoplasmic mucin vacuoles (B, ThinPrep, Papanicolaou ⫻400). Considering her advanced age and liver cirrhosis, we opted for endoscopic management instead of an open operation. A cholangiogram revealed a Bismuth type II⫺like, mobile, amorphous filling defect
956 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 6 : 2013
(C). We grasped and completely resected the mass in a piecemeal fashion with a retrieval balloon and Dormia basket under ERCP. The mass was grossly hemorrhagic and necrotic (D). Fragments of the mass showed nearly totally infarcted clusters of atypical cells (B, rectangle, H&E ⫻100) with hyperchromatic, pyknotic nuclei and prominent nucleoli (inset, *, H&E ⫻400). We made a diagnosis of a necrotic, rapidly growing hilar cholangiocarcinoma. Four months later, follow-up CT and ERCP showed no intraluminal mass at the hilum. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. In Hye Cha, MD, Jin Nam Kim, MD, Myoung Ki Oh, MD, Soo Hyung Ryu, MD, You Sun Kim, MD, Jeong Seop Moon, MD, Division of Gastroenterology, Department of Internal Medicine, Hye Kyung Lee, MD, Department of Pathology, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea http://dx.doi.org/10.1016/j.gie.2013.01.036
www.giejournal.org
Commentary Although first described more than a century ago, by Hellstrom in 1906, small intestinal lipomatosis remains a rare condition. Isolated lipomas are much more frequently encountered and, in the small intestine, are most common in the ileum. Lipomatosis affects both genders equally and typically occurs after the fourth decade of life. The lipomas in this condition are usually located in the submucosa but may extend through the bowel wall and into the serosal or mesenteric fat. Lipomas usually are silent, but they may ulcerate and bleed, or they may cause colicky abdominal pain because of intussusception. Jejunal lipomatosis has been reported in association with jejunal diverticulosis, ostensibly due to involvement and attenuation of the muscularis propria. CT scanning or CT enterography is the preferred diagnostic test for intestinal lipomatosis, although capsule endoscopy also can play a valuable role in demonstrating the lipomas. If the lipoma is within reach of the endoscope, a biopsy forceps may be used in several ways to prove the diagnosis. Before biopsy of the putative lipoma, however, the diagnosis might be suspected because of blood vessels that may be seen coursing over the lesion’s surface or an orange-red surface that changes to a more yellow color toward the base of the lesion. As the lesion is probed with a closed biopsy forceps, it indents and then springs back to its previous shape when the forceps is withdrawn: the so-called “pillow sign.” Immediately before the biopsy specimen is taken, the mucosa may be grasped with the forceps and pulled up: the so-called “tenting sign.” Upon biopsy, one may evoke the “naked fat sign,” a finding pathognomonic for lipoma during which fat spills out of the lesion after the biopsy. St Jerome said a fat stomach never breeds fine thoughts. Times have changed, and besides the insensitivity of the comment, I am sure he was referring to the abdomen, not the stomach, and that he had never heard of lipid islands in the stomach or gastrointestinal lipomatosis. Lawrence J. Brandt, MD Associate Editor for Focal Points
Endoscopic removal of a bullet after mediastinum gunshot injury
A 39-year-old policeman was admitted to our emergency department with a thoracic gunshot injury. His only symptom was local pain, without dyspnea, hemoptysis, or hematemesis. On physical examination, a bullet entry wound was seen in the left midclavicular line, and www.giejournal.org
no exit wound or subcutaneous emphysema was identified. Angiotomography showed the bullet lodged at the T1-T2 level, without vascular lesions. An esophagogram revealed the bullet in the upper mediastinum, causing deviation of the esophagus without extravasaVolume 77, No. 6 : 2013 GASTROINTESTINAL ENDOSCOPY 955
At the Focal Point
tion of contrast medium. Upper endoscopy demonstrated an elevated area with a small fistulous orifice (A, arrow). Once the patient was asymptomatic, conservative treatment was adopted. After nasoenteral feeding for 5 days, an oral diet was introduced with good acceptance. Weekly serial endoscopies demonstrated progressive migration of the bullet to the esophageal lumen (B). Twenty-seven days after the trauma, the bullet was removed with alligator forceps. An orifice with adjacent edema was noted at the impact site of the bullet. (C). One week later, the endoscopic study revealed healing of the bullet track and regenerating mucosa adjacent to the site of the previous fistula (D). The patient remained asymptomatic during a 6-month follow-up period.
DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Cristiane Kibune Nagasako, MD, MSc, Ciro Garcia Montes, MD, PhD, Endoscopy Unit of Gastrocentro, Luiz Roberto Lopes, MD, PhD, Department of Surgery, Marina da Silveira Bossi, MD, Endoscopy Unit of Gastrocentro, Maria Aparecida Mesquita, MD, PhD, Gastroenterology Division, Faculty of Medical Sciences, State University of Campinas, Campinas, Brazil http://dx.doi.org/10.1016/j.gie.2013.01.038
Commentary I gotta say this is one of my favorite Focal Points of all time. But without high-tech imagery, obscure once-in-a-lifetime diagnoses, and cutting-edge, high-risk endoscopic solutions—what makes it so cool? Because it beautifully demonstrates both the principles of primum non nocere and cura te ipsum (cure yourself). What drives the microcurrents that wend wayward foreign bodies to the nearest exit (in the case of a splinter, to the outside world; in this case, to the esophageal lumen), and how do they know in what direction to flow? This migratory phenomenon is just one of the wonderments the body does really well; add it to the list that includes hepatic lobar regeneration and about a million others. The authors were prudent to let nature take her course; the close endoscopic surveillance and well-timed armament recovery mission prevented yet more trouble for this remarkably lucky cop. David Robbins, MD, MSc Assistant Editor for Focal Points
Total necrosis of rapid growing hilar cholangiocarcinoma An 81-year-old woman with cryptogenic liver cirrhosis presented with right upper quadrant pain and pruritus. A complete blood cell count showed a hemoglobin of 11.8 g/dL (normal range, 12.0-16.0 g/dL), white blood cell count of 3340 cells/L (normal range, 4000-10,000 cells/ L), and a platelet count of 83,000/L (normal range, 150,000-400,000/L). Liver biochemical tests revealed aspartate aminotransferase of 51 IU/L (normal range, 0-31 IU/L), alanine aminotransferase of 55 IU/L (normal range, 0-31 IU/L), alkaline phosphatase of 179 IU/L (normal range, 39-117 IU/L), and a total bilirubin of 7.3 mg/dL (normal range, 0.2-1.3 mg/dL). A 2-cm moderately attenuated nodular mass at the hilum, not seen on a CT 3 months previously, was noted on abdominal CT (A, arrow). A nasobiliary catheter was inserted for decompression of the bile duct. Fluid cytology showed a few syncytial clusters of malignant columnar cells with prominent nucleoli and intracytoplasmic mucin vacuoles (B, ThinPrep, Papanicolaou ⫻400). Considering her advanced age and liver cirrhosis, we opted for endoscopic management instead of an open operation. A cholangiogram revealed a Bismuth type II⫺like, mobile, amorphous filling defect
956 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 6 : 2013
(C). We grasped and completely resected the mass in a piecemeal fashion with a retrieval balloon and Dormia basket under ERCP. The mass was grossly hemorrhagic and necrotic (D). Fragments of the mass showed nearly totally infarcted clusters of atypical cells (B, rectangle, H&E ⫻100) with hyperchromatic, pyknotic nuclei and prominent nucleoli (inset, *, H&E ⫻400). We made a diagnosis of a necrotic, rapidly growing hilar cholangiocarcinoma. Four months later, follow-up CT and ERCP showed no intraluminal mass at the hilum. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. In Hye Cha, MD, Jin Nam Kim, MD, Myoung Ki Oh, MD, Soo Hyung Ryu, MD, You Sun Kim, MD, Jeong Seop Moon, MD, Division of Gastroenterology, Department of Internal Medicine, Hye Kyung Lee, MD, Department of Pathology, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea http://dx.doi.org/10.1016/j.gie.2013.01.036
www.giejournal.org