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EUS demonstration of nonlifting sign in a dysplastic polyp at the appendiceal orifice
VideoGIE
Adverse events of Behçet’s disease (BD) related to ulcers such as fistula, hemorrhage, and perforation occur in up to 50% of cases. Although these adverse events require invasive surgery, recurrence is frequently observed. Therefore, a minimally invasive treatment is necessary for patients with BD. Here we describe the first case of using over-the-scope clips (OTSCs; Ovesco Endoscopy GmbH, Tübingen, Germany) for small intestinal ulcers of BD. A 79-year-old man presented with severe intestinal bleeding from an ileal stoma. The patient had undergone emergent surgery for repair of a perforated sigmoid ulcer 1 week before presentation. Endoscopic findings via the stoma revealed several ulcers, 2 of which required treatment: an ulcer exhibiting continuous bleeding and a deep ulcer exposing the ileal muscle layer (Fig. 1A and B; Video 1, available online at www.giejournal.org). Thus, OTSCs were considered the most suitable treatment for these ulcers. After informed consent was obtained, the defects were successfully closed, which resulted in complete hemostasis (Fig. 1C and D). Despite being unable to aspirate the entire defect of 1 bleeding ulcer into the OTSC mounting cap, we achieved complete closure by placing 2 OTSCs on the ulcer without incorporating the clips during closure. Three months later, after the application of infliximab, the mucosal healing of 1 ulcer and the continuous complete closure of the deep ulcer were confirmed (Fig. 1E and F). In conclusion, this case demonstrates that OTSC deployment is an effective minimally invasive treatment
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store. option for the management of bleeding and perforations in patients with BD. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Noriko Nishiyama, MD, Hirohito Mori, PhD, Hideki Kobara, PhD, Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Japan, Kazi Rafiq, PhD, Department of Pharmacology, Faculty of Medicine, Kagawa University, Japan, Shintaro Fujihara, MD, Maki Ayaki, MD, Tatsuo Yachida, MD, Yasuhiro Goda, MD, Asahiro Morishita, PhD, Tsutomu Masaki, PhD, Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Japan
http://dx.doi.org/10.1016/j.gie.2014.09.052
EUS demonstration of nonlifting sign in a dysplastic polyp at the appendiceal orifice
Figure 1. A, Flat polyp at appendiceal orifice. B, EUS (20 MHz) demonstrating a hypoechoic lesion arising from the mucosa and invading into the submucosa. C, Nonlifting sign after injection of dilute indigo carmine.
An 85-year-old man underwent colonoscopy and was found to have a flat polyp at the appendiceal orifice. Biopsy specimens revealed a tubular adenoma with high-grade dysplasia (HGD). The patient was referred
for endoscopic resection. A 1-cm horseshoe-shaped flat polyp was found (Fig. 1A; Video 1, available online at www.giejournal.org). EUS was performed with the 20MHz miniprobe, revealing a hypoechoic lesion arising
1276 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5 : 2015
www.giejournal.org
VideoGIE
from the mucosa and invading the submucosa (Fig. 1B). Submucosal injection of a dilute indigo carmine solution resulted in a nonlifting sign, consistent with submucosal invasion (Fig. 1C). Biopsy specimens revealed HGD and findings suspicious for submucosal tumor invasion. The patient was thus referred for surgical resection. Laparoscopic right hemicolectomy was performed. Final surgical pathology revealed foci of residual HGD but no evidence of any invasive cancer; 23 lymph nodes were removed, and all were benign. This case highlights the potential downside of performing biopsies on, but not removing, flat or suspicious colon polyps. The resultant fibrotic reaction may mimic submucosal tumor invasion and preclude successful endoscopic resection. In cases in which a colon polyp is encountered, but the endoscopist is not comfortable removing it, referral to an expert center should be considered before attempting biopsies or partial removal.
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Christopher J. DiMaio, MD, FASGE, Dr. Henry D. Janowitz, Division of Gastroenterology, Noam Harpaz, MD, PhD, Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
http://dx.doi.org/10.1016/j.gie.2014.07.045
Retrograde single-balloon enteroscopy for the removal of an ileal foreign body
Figure 1. Triangular bony fragment extracted from the distal ileum.
A 51-year-old obese woman presented with acute, severe epigastric abdominal pain. She was hemodynamically stable with unrevealing lab work. A CT of the abdomen and pelvis revealed a radiopaque foreign body in the distal ileum with penetration of the ileal wall and a focus of extraluminal gas; there was no abscess or pneumoperitoneum. www.giejournal.org
We performed a retrograde single-balloon enteroscopy (SBE) with CO2 insufflation by inserting the endoscope through the rectum, advancing to the cecum, and intubating the ileocecal valve. At approximately 20 cm proximal to the valve, a bony fragment was seen with mucosal penetration. The fragment was extracted with forceps and withdrawn into the overtube; the SBE apparatus was then slowly Volume 81, No. 5 : 2015 GASTROINTESTINAL ENDOSCOPY 1277
Adverse events of Behçet’s disease (BD) related to ulcers such as fistula, hemorrhage, and perforation occur in up to 50% of cases. Although these adverse events require invasive surgery, recurrence is frequently observed. Therefore, a minimally invasive treatment is necessary for patients with BD. Here we describe the first case of using over-the-scope clips (OTSCs; Ovesco Endoscopy GmbH, Tübingen, Germany) for small intestinal ulcers of BD. A 79-year-old man presented with severe intestinal bleeding from an ileal stoma. The patient had undergone emergent surgery for repair of a perforated sigmoid ulcer 1 week before presentation. Endoscopic findings via the stoma revealed several ulcers, 2 of which required treatment: an ulcer exhibiting continuous bleeding and a deep ulcer exposing the ileal muscle layer (Fig. 1A and B; Video 1, available online at www.giejournal.org). Thus, OTSCs were considered the most suitable treatment for these ulcers. After informed consent was obtained, the defects were successfully closed, which resulted in complete hemostasis (Fig. 1C and D). Despite being unable to aspirate the entire defect of 1 bleeding ulcer into the OTSC mounting cap, we achieved complete closure by placing 2 OTSCs on the ulcer without incorporating the clips during closure. Three months later, after the application of infliximab, the mucosal healing of 1 ulcer and the continuous complete closure of the deep ulcer were confirmed (Fig. 1E and F). In conclusion, this case demonstrates that OTSC deployment is an effective minimally invasive treatment
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store. option for the management of bleeding and perforations in patients with BD. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Noriko Nishiyama, MD, Hirohito Mori, PhD, Hideki Kobara, PhD, Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Japan, Kazi Rafiq, PhD, Department of Pharmacology, Faculty of Medicine, Kagawa University, Japan, Shintaro Fujihara, MD, Maki Ayaki, MD, Tatsuo Yachida, MD, Yasuhiro Goda, MD, Asahiro Morishita, PhD, Tsutomu Masaki, PhD, Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Japan
http://dx.doi.org/10.1016/j.gie.2014.09.052
EUS demonstration of nonlifting sign in a dysplastic polyp at the appendiceal orifice
Figure 1. A, Flat polyp at appendiceal orifice. B, EUS (20 MHz) demonstrating a hypoechoic lesion arising from the mucosa and invading into the submucosa. C, Nonlifting sign after injection of dilute indigo carmine.
An 85-year-old man underwent colonoscopy and was found to have a flat polyp at the appendiceal orifice. Biopsy specimens revealed a tubular adenoma with high-grade dysplasia (HGD). The patient was referred
for endoscopic resection. A 1-cm horseshoe-shaped flat polyp was found (Fig. 1A; Video 1, available online at www.giejournal.org). EUS was performed with the 20MHz miniprobe, revealing a hypoechoic lesion arising
1276 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5 : 2015
www.giejournal.org
VideoGIE
from the mucosa and invading the submucosa (Fig. 1B). Submucosal injection of a dilute indigo carmine solution resulted in a nonlifting sign, consistent with submucosal invasion (Fig. 1C). Biopsy specimens revealed HGD and findings suspicious for submucosal tumor invasion. The patient was thus referred for surgical resection. Laparoscopic right hemicolectomy was performed. Final surgical pathology revealed foci of residual HGD but no evidence of any invasive cancer; 23 lymph nodes were removed, and all were benign. This case highlights the potential downside of performing biopsies on, but not removing, flat or suspicious colon polyps. The resultant fibrotic reaction may mimic submucosal tumor invasion and preclude successful endoscopic resection. In cases in which a colon polyp is encountered, but the endoscopist is not comfortable removing it, referral to an expert center should be considered before attempting biopsies or partial removal.
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Christopher J. DiMaio, MD, FASGE, Dr. Henry D. Janowitz, Division of Gastroenterology, Noam Harpaz, MD, PhD, Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
http://dx.doi.org/10.1016/j.gie.2014.07.045
Retrograde single-balloon enteroscopy for the removal of an ileal foreign body
Figure 1. Triangular bony fragment extracted from the distal ileum.
A 51-year-old obese woman presented with acute, severe epigastric abdominal pain. She was hemodynamically stable with unrevealing lab work. A CT of the abdomen and pelvis revealed a radiopaque foreign body in the distal ileum with penetration of the ileal wall and a focus of extraluminal gas; there was no abscess or pneumoperitoneum. www.giejournal.org
We performed a retrograde single-balloon enteroscopy (SBE) with CO2 insufflation by inserting the endoscope through the rectum, advancing to the cecum, and intubating the ileocecal valve. At approximately 20 cm proximal to the valve, a bony fragment was seen with mucosal penetration. The fragment was extracted with forceps and withdrawn into the overtube; the SBE apparatus was then slowly Volume 81, No. 5 : 2015 GASTROINTESTINAL ENDOSCOPY 1277