Managing Necrotizing Gastritis, Fundoplication Evaluation & More
Key discussions, challenging cases, and practice-enhancing pearls shared by our expert group.
Weekly Insights from the EndoCollab Community
Here's a snapshot of the key discussions and learning points from our group this week:
Technical Challenges in Endoscopy:
A participant inquired about difficulties encountered while attempting to pass a ligator system.
A solution involving the use of an esophageal overtube (Steris) to facilitate the advancement of the scope with the ligating system was shared. The use of an over-the-scope clip for bleeding peptic ulcers was also suggested in a similar context of challenging passage.
Inflammatory Bowel Disease (IBD) Management:
A discussion arose regarding therapeutic options for IBD, with Infliximab (IFX) and Ustekinumab being proposed as potential treatments.
Fellowship Opportunities:
Information regarding Gastrointestinal Fellowship in Advanced Endoscopy opportunities in Canada was shared.
Interesting Case: Ascaris Lumbricoides Infestation:
A case of chronic bloating and excessive gas was presented, where previous endoscopies at other centers were inconclusive.
A subsequent colonoscopy revealed and facilitated the successful endoscopic removal of Ascaris worms.
A discussion ensued regarding the optimal management strategy: endoscopic removal versus direct treatment with Albendazole.
Points raised included:
The benefit of immediate removal for diagnostic confirmation and potential symptom relief.
The efficacy of Albendazole and whether endoscopic removal was necessary in the absence of obstructive symptoms.
The theoretical possibility of encountering drug-resistant strains, although this is not a primary area of research.
The possibility of retrieving the worm with standard biopsy forceps.
Colonoscopy Considerations in Patients with Hernias:
An urgent query was raised regarding whether an inguinal hernia constitutes a contraindication for colonoscopy.
The consensus was that a reducible hernia is generally not a contraindication.
Concerns were raised about potential challenges with ileal intubation in cases of right-sided hernias.
A participant shared a personal experience of encountering a large scrotal hernia during a colonoscopy, which was successfully managed by manual reduction.
A case report and literature review on incarcerated colonoscope in an inguinal hernia was shared, highlighting that many such hernias are previously unknown.
Rare Presentation: Suspected Necrotizing Gastritis:
A case of a 61-year-old male with ESRD on dialysis and morbid obesity, presenting with nausea and vomiting, revealed concerning findings on upper endoscopy suggestive of necrosis.
Emphysematous gastritis was considered as a possible differential diagnosis.
Treatment strategies discussed included supportive care (NPO, IV fluids, parenteral feeding) and antibiotics.
The role of surgical intervention was debated, with opinions suggesting it has high mortality and is not superior to medical management in most cases.
Sarcina ventriculi was suggested as a potential causative organism for emphysematous or necrotizing gastritis.
Differential Diagnosis: Fundal Gastric Antral Vascular Ectasia (GAVE):
As an alternative hypothesis for the previous case, Fundal Gastric Antral Vascular Ectasia (GAVE) was proposed, and relevant literature was shared.
The association of GAVE with conditions like cirrhosis, chronic kidney disease, hypothyroidism, and autoimmune disorders was highlighted.
Post-Fundoplication Evaluation:
A video of an endoscopic evaluation post fundoplication was shared in a 40-year-old patient experiencing frequent vomiting one year after the procedure.
The quality and type of fundoplication were discussed, with opinions suggesting it appeared to be a well-performed Nissen fundoplication or a 270-degree fundoplication. The possibility of it being "plicated too well" was also raised as a potential factor in the patient's symptoms.
Inquiry on Hepatic Hemangioma Management:
A question was posed regarding the guidelines for treating hepatic hemangioma. This topic may be explored further in subsequent discussions.
EndoCollab Posts
1. Evaluation and Management of Portal Vein Thrombosis in Cirrhosis
• Key Takeaways:
• Anticoagulation recommended for fresh DVT with >50% obstruction.
• Chronic cases with cavernomas typically do not require anticoagulation.
• DOACs are safe in patients with compensated cirrhosis.
• TIPS (Transjugular Intrahepatic Portosystemic Shunt) is viable in selected cases.
• Regular follow-up with imaging (Doppler ultrasound or CTA every 3 months) is critical.
• Source: Gastroenterology Journal
2. Candida Esophagitis – Quick Guide
• A concise clinical update on Candida esophagitis, emphasizing endoscopic findings, antifungal therapies, and risk factor evaluation.
3. Cap-Assisted Push Enteroscopy with Argon Plasma Coagulation
• A detailed case involving melena with bleeding localized in the proximal jejunum.
• Techniques Highlighted:
• Use of cap-assisted pediatric colonoscope for better visualization and stabilization.
• Water-aided endoscopy for orientation and lesion localization.
• Successful treatment of angiodysplasia using argon plasma coagulation.
• Clinical Pearls:
• Push enteroscopy can replace balloon enteroscopy for upper jejunal lesions.
• Transparent caps improve navigation and therapeutic precision.
4. Gastric Antral Vascular Ectasia (GAVE) in Heyde Syndrome
• Case Summary:
• 80-year-old female with recurrent GI bleeding linked to acquired von Willebrand disease.
• Nodular GAVE identified and treated via endoscopic band ligation.
• Key Insight:
• Heyde syndrome redefined as a hemophilia variant (acquired von Willebrand syndrome) causing angiodysplasias throughout the GI tract.
5. Managing Anastomotic Stenosis in Post-Low Anterior Resection
• Discussion on whether to biopsy and dilate an anastomotic stenosis in a patient post-radiotherapy and surgery for rectal cancer.
• Group consensus leaned toward careful dilation after biopsy confirmation of the lesion.
6. Weekly Digest Highlights (Dec 16–22, 2024)
• Ulcerative Colitis vs. Crohn’s Disease imaging considerations.
• Timing of PEG placements post-dental extractions.
• Antibiotic-induced side effects and recommended alternatives.
• Updated guidance on H. pylori eradication protocols.
• Techniques for crushing Epclusa for PEG/NG tube administration.
7. Pediatric Foreign Body Extraction
• Successful endoscopic extraction of an open imperdible (safety pin) in a 7-month-old infant.
• Highlights the importance of expertise in pediatric endoscopy for managing foreign bodies.
This week's discussions highlighted the diverse challenges and interesting cases encountered in our field, fostering valuable knowledge exchange and collaborative problem-solving.