EndoCollab Weekly Digest: Caustic Injury Management, Juvenile Polyps, and Clinical Updates (Jan 8-14, 2025
Key discussions, challenging cases, and practice-enhancing pearls shared by our expert group.
EndoCollab Weekly Summary (Week of January 8–14, 2025)
Key Discussions and Cases:
• Sporadic Juvenile Colon Polyp
• A 20 mm juvenile polyp was discovered and successfully resected during colonoscopy in a 29-year-old patient.
• A query was raised regarding the necessity of performing a gastroscopy in such cases to exclude other possible locations and evaluate for Juvenile Polyposis Syndrome (JPS).
• Highlights the importance of recognizing the syndromic potential in juvenile polyps and tailoring post-polypectomy evaluations accordingly.
• Argon Plasma Coagulation (APC) in Edematous Rectal Mucosa
• A practical question was posed on whether to proceed or halt APC therapy when faced with edematous rectal mucosa during the procedure.
• This sparked a discussion about managing complications such as edema during APC and ensuring safe mucosal ablation while avoiding adverse events.
• Micronodules in the Duodenal Bulb
• A 30-year-old patient with dyspepsia was found to have white micronodules in the duodenal bulb.
• Questions centered on whether these micronodules are pathological, potential underlying causes, and the necessity of biopsies in such presentations.
• Possible considerations include Celiac Disease, lymphoid hyperplasia, or other inflammatory changes, underscoring the need for biopsy in ambiguous cases.
• Ingestion of Cylindrical Batteries: Optimal Timing for Removal
• A discussion focused on the management of cylindrical battery ingestion and the optimal timing for endoscopic removal if the battery remains in the stomach (48 vs. 72 hours).
• This discussion highlights the critical importance of timely intervention to prevent complications such as mucosal damage, perforation, or leakage of battery contents.
Key Takeaways:
• Juvenile Polyps: The need for further diagnostic evaluation, such as gastroscopy, should be considered in cases of juvenile polyp resection to exclude syndromic causes.
• APC and Edema: Decisions during APC therapy should weigh mucosal conditions to avoid further injury while achieving therapeutic outcomes.
• Duodenal Micronodules: When encountering ambiguous endoscopic findings like micronodules, biopsies remain a key step in elucidating the etiology.
• Battery Ingestion: Clinical consensus on intervention timing is crucial for minimizing risks of severe complications.
Feel free to explore the full discussions and contribute your insights using the provided links!
Weekly Summary: WhatsApp Group (January 7–14, 2025)
Key Discussions
• Caustic Ingestion Management:
• A 24-year-old male ingested sodium hydroxide in a suicide attempt, leading to esophageal (Zargar IIA) and gastric injuries (Zargar IIIb).
• Debate on early interventions such as dilation and the role of IV corticosteroids for caustic injuries:
• IV dexamethasone is recommended only for grade IIb esophagitis to reduce stricture risk.
• No strong evidence supports corticosteroids in grade IIA injuries.
• Patient experienced rapid deterioration and multiorgan failure, raising suspicions of concurrent toxic ingestion or aspiration pneumonitis.
• Thromboprophylaxis and Gastrostomy:
• Safety of gastrostomy in patients on enoxaparin (40 mg daily) discussed.
• Consensus: Perform gastrostomy 12 hours after the last dose of enoxaparin to reduce bleeding risk, aligned with ASGE recommendations.
• Surveillance Practices:
• Barret’s Esophagus: Minimal agreement on surveillance intervals due to the low incidence of esophageal adenocarcinoma (EAC) in certain cases.
• Ectopic Pancreas in Gastric Antrum: Most members advised against intervention in asymptomatic patients.
• Diagnostic Challenges:
• A D3 submucosal lesion seen on CT and OGD led to discussion about biopsy techniques (SINK biopsy preferred for small lesions).
• Shiga toxin-producing E. coli: Importance of avoiding antibiotics to prevent hemolytic uremic syndrome (HUS) highlighted.
Clinical Pearls
• Caustic Injuries:
• Liquefactive necrosis (alkalis) causes deeper esophageal damage compared to the superficial damage of coagulative necrosis (acids).
• The severity of damage correlates with the quantity ingested and stomach contents at the time of ingestion.
• Early endoscopy is critical but must be carefully weighed against the patient’s stability.
• Endoscopic Techniques:
• SINK biopsy is favored for small, submucosal lesions due to efficacy and cost-effectiveness.
• Surveillance is unnecessary for asymptomatic gastric subepithelial lesions unless complications like bleeding or pancreatitis are evident.
• Infectious Diarrhea:
• Chronic diarrhea from E. coli strains may necessitate further investigation if associated with anemia or systemic symptoms.
• Antibiotic treatment should be avoided in Shiga toxin-producing strains unless absolutely necessary.
Interesting Case Studies
1. Caustic Ingestion: Rapid progression to fatality highlights the need for multidisciplinary care and access to toxicology support.
2. Recurrent Epigastric Pain: Possible retroperitoneal appendicitis resolved with symptomatic management, raising questions about surgical indications.
Educational Resources & Recommendations
• ASGE guidelines for anticoagulation management in GI procedures.
• Literature on caustic injury management and surveillance strategies for Barrett’s Esophagus.
• Endoscopic resources, including SINK biopsy techniques and EUS imaging.
Community Collaboration:
• Ongoing support for colleagues with questions on uncommon cases and guidelines.
• Encouragement of group initiatives to reduce disparities in gastroenterology services globally.