Weekly Highlights: PTLD, Bouveret’s Syndrome, and Parasite Diagnostics
Exploring Complex Gastrointestinal Cases and Cutting-Edge Endoscopic Strategies
Weekly Discussion Overview on EndoCollab
Post-Transplant Lymphoproliferative Disorder (PTLD):
• PTLD exhibits varied endoluminal manifestations, including edema, deformity, nodularity, pseudopolyps, fibrosis, and stenosis due to its infiltrative nature.
• Biopsy may be required even in areas of normal mucosa if PTLD is suspected.
• A shared case emphasized its desmoplastic, submucosal reaction and clinical management.
Cholecystoduodenal Fistula with Large Stones:
• Discussion around a case involving a gangrenous perforated cholecystitis with large stones blocking the duodenal bulb.
• Management strategies debated included mechanical lithotripsy and endoscopic stone retrieval.
• Consensus leaned towards attempting removal of stones, particularly those exceeding 2.5 cm, to avoid complications such as biliary ileus.
Bouveret’s Syndrome:
• A rare case involving duodenal obstruction by gallstones with challenges in retrieval was shared.
• Recommendations included lithotripsy and careful monitoring of obstructive symptoms, highlighting the importance of imaging and clinical presentation.
Endoscopic Management of Body Packers:
• A challenging case of heroin bag rupture within the gastrointestinal tract was discussed.
• ESGE guidelines caution against endoscopic retrieval due to rupture risks; however, endoscopic retrieval attempts were made.
• Surgical intervention was ultimately required after failed retrieval, with a favorable outcome.
Chronic Diarrhea and Intestinal Parasites:
• A case of chronic diarrhea with ileal ulceration and suspected parasitic etiology:
• Differential diagnosis included Trichuris trichiura (Whipworm), hookworm, Strongyloides stercoralis, and Anisakis.
• Geographic relevance and patient history (e.g., raw fish consumption, endemic regions) played a crucial role in narrowing down the diagnosis.
• Discussion underscored the need for biopsy confirmation and the significance of aphthous ulcers in diagnostic algorithms.
Endoscopic Techniques and Equipment:
• Queries regarding optimal techniques and tools for specific endoscopic interventions:
• Use of OTSC (Over-The-Scope Clip) for PEG site closure.
• Recommendations for resources, including the EndoCollab app, were shared for further guidance.
Key Takeaways:
• Multidisciplinary Collaboration: Complex cases such as PTLD and body packers benefit from combining endoscopic expertise with surgical input.
• Importance of Imaging and Biopsy: Accurate diagnosis in gastrointestinal conditions often hinges on high-quality imaging and histopathological confirmation.
• Geographic and Clinical Contexts: Recognizing regional prevalence of parasitic infections aids in accurate diagnosis and management.
• Emerging Tools and Techniques: Adoption of advanced tools like OTSC and lithotripsy continues to refine interventional endoscopy.
Notable Quotes:
• “One Whipworm will not cause chronic diarrhea; massive infestation is required for significant symptoms.”
• “Stones less than 2.5 cm can pass the ileocecal valve, but careful observation is necessary.”
This week’s discussions underscored the diversity of cases encountered in gastroenterology and the value of collaborative problem-solving in complex scenarios.