Video Endoscopy Conference 1/8/21 Play Pause Volume Quality 1080P 720P 576P Fullscreen Captions Transcript Chapters Slides Endoscopy Conference 1/8/21 Overview Three cases presented here: • 00:00 – Non-occlusive Colonic Ischemia • 16:57 – EBV-associated Mucocutaneous Ulceration vs PTLD • 33:54 – Intragastric Balloon morning, everyone. Welcome back to endoscopy conference our first of the new year. Um, let's go ahead and get started. We'll have Jamila one of our first year fellas. Go ahead and present. Okay, Let me share my screen. Okay? Yeah. Mhm. And can can you guys let me know if you see the how our pointer. If you see the presenter slide, we see Presenter View. Okay, That's what I thought. Let me try that again, Mr. How about now? Okay, great. All right. So I'll start off with the first case. Um, so we have a 68 year old woman with a history of stage four diffuse large B cell lymphoma. Um, and, uh, lung cancer. And she status both several cycles of chemotherapy. Um, hypertension, COPD. She presents the edie with one day of severe abdominal pain and bloody diarrhea. She's him or him, or dynamically stable. A federal tender throughout her whole abdomen. But there's no rebound or guarding. And her initial labs, um, including hemoglobin of 12.9. Um, which is her baseline and a white count of 30. Um, with a baseline of a normal, uh, normal range. Be one at 30 creating a 300.9 and elected to true. She ultimately got a C. T. And it showed market wall thickening and hyper hyper mania of the descending and sigmoid colon compatible with colitis. So we were consulted for endoscopic evaluation, and we ultimately did a flex sig given kind of localization of disease and kind of as we are entering into the rectum, the rectum, as you can tell, is spared without any evidence of, um, obvious disease. The distal sigmoid does have this linear ulceration in the longitudinal access, and then the rest of the distal sigmoid has kind of worsening of alterations. Now, involving more of the mucosa and kind of this, uh, kind of this endoscopic along this path and no path demonic to the disease process that we'll talk about. And this is called a single stripe sign, um, and continuing our flex sick. The rest of the sigmoid, um, again has worsening ulceration. Now, involving the more, uh, circumference of the colon and then the involves the descending colon. Um, and we stop essentially at the most, the distal most extent of the disease. And so we didn't actually take biopsies because we have a high clinical suspicion of what? This ultimately what we ultimately call this, which is a schematic colitis or non inclusive colonic ischemia. I know that we've talked about this, Um, but, you know, I think it's always a good thing to review. And so what is ischemic colitis? It's sudden and usually transient reduction in blood flow to the Poland causing cellular metabolic dysfunction of Kelowna sites. Um, in most cases, no specific cause is identified. However, they are risk factors, including cardiovascular disease. Most vulnerably myocardial infarction in recent cabbage, um, diabetes, renal disease. And for patients who are actually on, uh, chemo day, uh, hemodialysis, uh, thought you thought to be from dialysis induced hypertension. Um, shock, for obvious reasons due to the low flow state, Um, they're actually having reports of I B. S, um, being correlated, uh, to ischemic colitis. And there have also been many reports on several culprits. Um, such as constipation inducing medications like opioids, immuno modulators such as anti TNF schemo. Um, an illicit drugs such as cocaine and extreme exercise can also be risk factors because, as you can imagine, um, when there's intense exercise, there's, uh, shunting of the blood flow from the Atlantic. Circulation, uh, commonly affects the watershed areas, um, commonly director sigmoid junction and the splenic fracture. The left colon is mostly affected in about 75% of cases, the rectum is usually spared, as it was in this case. It usually affects about 5% of cases. And if you have isolated right colon colitis, um, ischemic colitis, that's usually associated with higher mortality rates. Uh, 90% of patients are usually greater than 60 years old, and I think it equally affects men and women. However, there are poor outcomes, Um, in male patients and then the most common presentation, most common presentation is mild abdominal cramping with an urgent desire to dedicate. There's some some pills I did anything I should know about or Mm. I know Tony was dealing with the patient portal. Yeah, What's happening with Sylvie? I think that might be I don't know if I can meet him. If you ever give me her phone number quarterly because Dr Jaffe fun and as good as not working, we need to know Dr Jeff in. Can we have you meet your phone or your computer? Thank you. Um, and so again. So sudden abdominal cramping with a sudden desire to defecate and passage of corrective within 24 hours and often associated with bloody diarrhea and briefly just wanted a contrast. Ischemic colitis with acute inclusive message. Eric Ischemia. Because often times I feel like we use them. Um, as like, uh, I think these terms of common misnomers and they're used interchangeably. Although there are two distinct disease processes and so must attack, ischemia often affects the small bowel. It's usually inclusive from from 1 July disease. It's usually very sudden, and abdominal pain is out of proportion to physical exam. And it requires urgent surgical intervention, whereas a scheme of colitis mostly affects the colon, usually non inclusive, non inclusive due to low flow states. As I have mentioned, um, more gradual onset and the abdominal pain is actually mild to moderate. Um, oftentimes associate with bloody diarrhea, and the treatment is usually conservative, as I'll describe further on um, and so I wanted to take this time to just go over the A c g clinical guidelines and how to manage um, colon ischemia. I feel like I've seen varying clinical practice, and so I think it's always nice to review. Um, it's actually out in the literature. And so the two things I want to focus in on I want to focus on are the role of imaging and, uh, colonoscopy and the diagnosis of ischemic colitis. And then also, how do we manage the skin colitis based on disease process, um, and disease severity. And so C t is actually strongly recommended in terms of, um, obtaining this when you have a very high suspicion for colon ischemia. And the reason for that is is that the diagnosis can be very highly suggested based on CT findings, um, with bowel wall thickening and oedema. Um, and then, you know, at the very most, um, can help risk stratify if findings if you find um yeah, Kalanick, numerous new mitosis or proto Porto Moniz and Terek Venus gas. Um, and that can be suggestive of transnational Kalanick infarction. Um, which obviously is surgical. Um, indication early colonoscopy should be performed if skin colitis is, um suspected, and it should be performed in, uh, 48 hours of presentation. And this is also a strong recommendation. Um, I've seen I've seen clinically, uh, having a very high suspicion for skin colitis and deferring colonoscopy, Um, and treating conservatively according to the A C G, we should be getting colonoscopies and mostly to kind of rule out other ideologies. Um, in patients with severe ischemic colitis, uh, C t should be used to evaluate the distribution of disease. And it's, um, can be very helpful because I'm an entire colonoscopy isn't necessary. Limited colonoscopy is appropriate, um, to confirm the nature of C T abnormality similar to my case, we just did a flex segue, Um, and then it can be stopped at the distal most extent of the disease. Yes, biopsies should be obtained, except in cases of gangrene. We actually did not obtain biopsies for my patient, but it is a strong recommendation. According to the A. C. G. And then lastly, colonoscopy should not be performed if patients have any sign of acute peritonitis or irreversible ischemic changes such as gangrene or necrosis. These are all strong recommendations And how do we manage ischemic colitis? Um, so there are three strong recommendations, and so most cases actually are self resolved and actually don't require any specific therapy, and these are usually mild cases, and I'll go over what mild is defined as for more severe, um, scenarios requiring, uh, surgical requiring surgical intervention. Um, obviously, these are This would be a strong recommendation if these patients have any evidence of shock. Hypertension, tachycardia, abdominal pain without rectal bleeding is actually indicator of poor, poor prognosis. Um, and again, an isolated right sided ischemic colitis or pan colitis actually is also, um, an indicator of poor prognosis as well. And any presence of gangrene? Um, all of these would require some surgical evaluation, consultation and ultimately, um, intervention. And then kind of the middle group, the moderate, just moderate severity patients who I feel like we often see in, um in our hospital setting often require, um, antimicrobial therapy. And so HCG actually does recommend giving these patients antibiotics, and oftentimes that will end up being Cipro and fragile. And so how do we risk stratify these patients? And so if you look at this small table to the right, these are the recommendations that the A. C. G has in terms of what labs we should send if we have a strong clinical suspicion for skinny colitis and includes albumin and, uh, analyst CBC CMP ck Latin ldh. And obviously you want to make sure the patient doesn't have infectious colitis because that would be a completely different um, management. Um and so we want to make sure we get C d f and G i pcr to rule to rule those out. And so how do we risk stratify? And so a CG divides up severity between mild, moderate and severe mild being, um, so localized segmental disease seen on imaging with other otherwise no risk factors that they kind of noted in the moderate group. Um And so for mouth presentations, these patients can be observed, they can undergo supportive care with fluids and, you know, treating the underlying, um, kind of underlying ideology for a low flow state. But the moderate severity group, which I think the majority of the patients that we will see, um, if they have three of three of any of these, um uh factors including male gender, hypertension, tachycardia, abdominal pain without rectal bleeding, B u n. Greater than 20 hemoglobin less than 12 ldh greater than 3 50 or sodium greater than less than 1. 36 white count greater than 15. And lastly, um you know, moderate alteration. Seen on, um, seen endoscopic Lee. If they have three of these, and actually they fit into this category and do they do recommend at least getting surgery to evaluate, to have them on board, and kind of most importantly, providing them preventing the patients with antibiotic therapy. And again, as I mentioned, if they're severe, um, you know, which I think is actually obviously be more obvious with, you know, peritonitis and gangrene. Then that requires urgent surgical evaluation and ultimate treatment. And so my patient, um, did kind of fall into the moderate category. Um, she had a high Buon. She did have a high white count that actually nicely went down quite rapidly with antibiotic initiation. And then she did have some, uh, moderate ulceration seen on seen on her flex sick. And so she ultimately did get 5 to 7 days of Cipro fragile and ended up doing well and had no further episodes of rectal bleeding. Um, there is no, uh, recommendation or any evidence that suggests that we need to do repeat endoscopic evaluation for these patients. All right. Does anyone have any questions? Thank you, Jamila. Great presentation. Good review. Excellent pictures. Um, that's about as classic I single stripe stein as you're gonna ever see. Um, and you don't know. We don't see that very often, necessarily. So it's good to sort of show that, um, any thoughts from our viewers today? I think the decision about colonoscopy is always up for debate. If you kind of dig into the meat of the guidelines, they sort of walked back that strong recommendation a little bit. Um, but to me, that's that's the biggest point of controversy. Any anybody out there want to comment on whether they like, they like to scope these patients or not? Yeah, to me, if they're really if it's very classic and the symptoms are very mild, I'm not sure it actually adds very much, particularly by the time we wind up seeing them. You know, people come in almost as they're starting to get better a lot. You know, they've had the cramping, abdominal pain, maybe diarrhea. Um, and by the time they get through the e. D and evaluated, you know, if they say like, I'm feeling better, um, I think you can actually just observe those people say this is classic a scheme of colitis. But, um, you know, everybody treats this a little bit differently in your list of of conditions. Um, somehow you didn't single out atrial fibrillation, and I would just, um you mentioned my but you didn't mention a fib. And I always think of a fib or new. A fib is something that closes transient hypertension. Yeah, I'm on the notion worth doing if you change your diagnosis. Um, and the differentiation between you know, Kalanick's scheming acute Mesoamerica ischemia is a big one. Um, it's probably, you know, something this group is very familiar with, but it's really important to teach the rest of the planet this because it really makes a big I think, to just add to what they've said. Um, you know, so mild disease. It may not be. As for the other extreme, I've seen it someone's super sick on two or three pressers. And they're, uh, you know, they're imaging shows signing suggestion of colitis and the entire clinical picture just suggests is colonic ischemia. But in those cases, we often argued that the colonoscopy may not change management because these patients are not going to be surgical candidates in their current state. Um and so putting them through the, you know, an invasive procedure, uh, perhaps may not be the best option. So in those cases, also, we have refrained in the past. Um, Ali, uh, let's, uh, go on to your presentation. I was just going to mention also, I think the antibiotics are an interesting point, too, because the data behind it is all based on animal literature. Um, with bacterial translocation, it makes sense, but there's not much actual data for people, but anyway, I will start my presentation. So Good morning, everyone. I'm going to tell you about a case which may be familiar. Tourist. Some people, um, but not familiar to all of you And tell you what happened and what the diagnosis ended up being so briefly. This is a 35 year old woman, um, with Lupus, complicated by Lupus nephritis. Who had a renal transplant. Um, in May of 2000 and 19, she's on, um, sell Sep and b'elanna Sep. Um and she's presenting, um, with this vision and Dina facia for several months. So she initially presented to an outside G I in August of 2000 and 19, and the outside G. I performed any G which shouldn't esophageal ulcer. Um, and path was sort of negative for everything. Her what we got And she was started on a p B. I she didn't get better. And so they re scoped her in September, Um, of the same year, and it should persist and ulceration again. Biopsies were negative per report. They continue to her on the PB and then stern it on care if eight. And then I first met her in November. So several months later, who at the time when she was presenting with worsening of Diana's Asia and then also had dysplasia to solids greater than liquids and also weight loss in her bme was down to 15. So I referred her for e d day. Mhm. And, uh, this is what we saw. And I'm at the basically the G junction, and I'm going to be coming back approximately, um and so you can see what we see so you can see this really deep, cratered ulceration. Um, and then there's more ulceration as we go approximately, and it looks pretty awful. Um and so this is just further the video just shows us going and looking more so we don't need to watch the whole video. So here's a representative image. So it's a large circumferential penetrating a staff of Gill author. And, um, we took a bunch of biopsies. Pathology came back. Not so interesting. So obviously there is squamous mucosa with ulceration, but no viral inclusions. Fungus stain on the biopsies was negative. Immuno stains were negative for all the common culprits. I took brushing and there was no malignant cells, but there were a fungal organisms. So, um, we started her inflow Kanazawa. But we weren't sort of convinced. And we continued her on P p I and Liquid care of faith, but she really didn't improve and continue tablet loss. Um, we got in Asafa Graham at this time, which is shown on the left. Um and you can see with my arrows, um, where the area of diseases in the mid two distal esophagus, um and then also ct scan to see if there's anything beyond the esophagus and where it was going. And it just shows circumferential wall thickening. Um, and nothing sort of that was that useful at this time. So the question is what to do next. Does anybody want to say what they would have done? Ask them to do an electron microscopy on only esophageal biopsy to look for HIV. Wow. Good. That is not what we did. That choice be. So I called Chris. It was like cops in either, By the way, can you Can you do something and tell me what's going on? I had actually seen this patient in liver transplant clinic. So, um, so this is the first video that Chris took in. This is about one month later than my initial scope, and it looks even worse. It just looks horrific. So that's, like one area vocation, areas of ulceration, and you can see sort of a tissue around the ulcers. Um, doesn't look normal. That's her stomach. What's your differential at this point, you ask, mate. Yeah, Ali. Okay. So, I mean, I was not convinced this was just Canada. Um, and my biggest concern, which is why I kept on doing more testing, was for malignancy. Um, and specifically in her, I was very worried. Um I mean, she did a large hiatus. Hernia? Naturally. Um, so there was I mean, normal malignancies. um, are could be possible, like the original cancer. But, um, I was thinking on the lines of something associated with their transplant, Um, like, P t l D. Um, but or my opportunistic Tunis tick infection. So either is there cm fee there that we messed? Um, that was sort of the other thing that I was entertaining, but I didn't think it was just Canada. And I think we needed to get a diagnosis. Any other thoughts from the group I can see would be top of my list, too. So maybe sometimes just getting a needle biopsy somewhere deep in there to get something that's not inflammatory, although, you know, infection would certainly be, You know? I mean, infection is always the issue, right? Um, in these patients, and even though the first couple of sets of biopsies were negative I mean, I think you're right to keep considering that, too. And, yeah, she was really suffering at this point, which is also the concern. I mean, she was kept on losing weight. Um, really, like severe pain every time she ate. Yeah, I was concerning. So Chris took a bunch of biopsies. Um, didn't take I don't think you ended up needing a needle biopsy, but just took a lot of biopsies and just kept bypassing deeper. Um, and we got a better diagnosis. Um, and this is what the path should, which is quite interesting. So they showed Epstein Barr virus positive b cell lymphoid proliferation. Um, and they also showed evidence of Barrett's esophagus with metal plastic goblet cells. Um, and it was C M v positive, um, and HSV and A the two HSV's and GMs were both negative. Ali, it says involving squamous mucosa and cardiac tissue. Do you mean, like, gastric cardia or heart? I guess it could be biopsies. I don't think they were that. I think there's an extra c there. Got it. Thank you. You did not get the heart would be a first. Probably the last. So when I was looking at this and I was like, Oh, boy, um, so the first part when you're looking at, um, e B V b cell proliferation, the first thing that comes to mind is PTL dig. Um and then we're off to the left with this CMD So she was actually admitted because she was doing so poorly at this time. She was starting an I V ganciclovir, um, and actually had some improvement in your symptoms. Um, but this is really treating the c m v. Part of it. Um, and she also was on p ovale games acyclovir when she was discharged. But then to work up on the possible underlying PTL d, she underwent purple flow, which was negative. She got a CT, abdomen, pelvis in addition to the CT chest that she already had shown no adn apathy or other lesions. And then she also had a pet scan with gesture the diffuse uptake in the men in distal esophagus but no other hyper metabolic lesions. So basically, at this point, we have an isolated lesion in the esophagus with these v cell proliferation that's associated with E B. B. So, uh, team involved. And also we are closely talking with Dr Delaney from the, uh, transplant team, and what the diagnosis came down to was either a BB associated mucous cutaneous ulceration versus P. T. L. D. Post transplant lymphoma, proliferated disorder. And I wanted to talk about this a little bit. Um, it's sort of a complicated scenario, and I'm dichotomy rising them here, but they're all kind of part of a spectrum. And actually, for Pete L. D. There is no formal definition. And, um, some people include benign ideologies into P T l D. If there be self hyper proliferating states, although the more recent guidelines really just include neo plastic, um, be still hyper proliferating states. And so there are associated with E B V. There's often Varinia. The prevalence of renal transplant patients is about 5%. Um, it's more common in cardiac and lung transplants because they're more highly immuno suppressed, and it's more common in Children. Um, and it's really a diverse presentation, um, with greater than 20% extra nodal. The treatment for PTSD is a reduction in immuno suppression, but it often requires anti B cell therapy, local toxin ob and or chemotherapy. Um, and then we moved to E v. V associated with cutaneous. Also, you can think of this as sort of like the beginning spectrum of P. T l D. Or sort of a benign part of the pathology, so e VVS associated. But there's rare pyrenean. These patients really thought to be isolated to the mucosa, or cutaneous site that it's involving, um, and the pathology shows activated the selfie. No types, really? The treatment is reduction in immune suppression, and you don't really need more if it's just this e b b associated with cutaneous ulcer. So looking at our patient, um, she actually had a mild BBB Kyrenia at the time. Um, the ferry was 1 69 with a cut off being around 49. So it's very, very low, low amounts of Kyrenia and the path was consistent with activated B cells when they did the rest of the, you know, history, chemistry. Um, and so when you're looking at the literature, I mean there's not a ton of literature, But in general, um, they show that there's a favor of problem prognosis If you just have this mucous cutaneous closer. So the first, um, series that I show here on their seven patients with this disease. None had Varinia and all resolved with the reduction of immuno suppression. On the bottom case series, they had 26 patients who are immuno suppressed for various reasons. So some of them are HIV. Some of them were just old age, so obviously we can't change those, but six of the patients or on immunosuppressive medications, and all of them resolved with reduction of immuno suppression, again suggesting a favorable prognosis. So what do we do? We decrease her community. She was stopped on the ballot, except she was stopped on mmf, and she was put on back on tackle, which is what she was on initially, in a little bit of prednisone, her Dina facial resolved, and she gained weight. But she did have ongoing dysplasia. So I referred to back to Chris. And this is, um so this is in March now. So a couple of months later, you can see that all the esophageal ulceration are healed, But now that she has a significant stenosis, um, not allowing the scope to pass. So, uh, Chris dilated it, um, and we can skip some of the dilation, um, just to see the rest of the tissue. Um, And so once it's dilated, he's able to pass it and get into the stomach, and you can see all the ulceration is healed. Um, which is great. And then, um, the awesome good again in August again reminds Asia. And you can see the mucosa looks great compared to what it looked like before. Um, and she's doing really well. Obviously, we took repeat biopsies, and they've all been negative. So just to conclude E b b mucous cutaneous ulcers are on the spectrum of P t l D. But with a more indolent and benign course, it should be considered in patients that are immuno suppressed and have this Ostrava deal. Ulcer and treatment is immuno suppression reduction, and the prognosis is done. So that's all I got for you. Thank you, Ali. That's amazing. I don't know how you find these patients, but I'm glad that you do. The in the reports that you pulled up are the alterations this dramatic? Uh, so they don't They don't show any alterations that are quite this dramatic. Um, there is one case report that showed, um, yeah, very, very similar ulceration. But he ended up having a patient in the case report ended up having p t l d. And requiring chemotherapy. Um, and it also was a renal transplantation. So there is, um, one case report that was, like, similar presentation, but ended up having a much more aggressive course. So I think she was really lucky I think she was on that border of turning into, um, PTSD because there was some monoclonal for a proliferation on the biopsies. So I think, you know, But I think we caught her just in time before there was complete malignant transformation, and she was just able to be treated with immune suppression reduction. Ali, uh, thank you for presenting the follow up on this. It's awesome. Um, I don't I may have missed it, but when you Is it the reduction in immune suppression a temporary, uh, intervention, or is it a permanent reduction? And in all those case series you presented, was there an incidence of, uh uh, you know, rejection in any of these patients? Is that a major concern? Or like, can you go back to their normal immune suppression? So a lot of those are not, uh, you know, there's very few patients who are, like, follow her perfectly as being a transplant patient. Some of these are just like, um, actually, a lot of them are rheumatoid arthritis patients that were just on methotrexate. So they were able to just get off that in transplant patients. Um, there were some cases where they discussed that there was relapse of the ulcer, um, when they increased the immuno suppression. Because the thing is, we're not getting rid of E v v completely. Um, so that can be an issue. Um, for right now, you know, she has had a little bumping and crashing, but it's been stable. She was actually initially just on tackling and prayed, but then had to be on a stronger immune suppression regimen because of early rejection, which is why she was on this lasts up and everything else, um, so definitely going to be complicated going forward with her. But she seems at least a handful from now and not having issues. I mean, hopefully they have. I mean, she's so young, she's got her whole life ahead of her, and this is going to be a major balancing act. Hopefully, they come out with next generation immunosuppressants and or treatments against better treatments against CPV or something like that. That's gonna be tough. Yeah, um, but yeah, I mean, I thought it was even though I know it's gonna be a complicated case going forward, I think you know, it's a really a little bit of feel good New York story about how well she did. Just with a little changes in her medications of it. Yeah, it's a pretty impressive story, and the pictures are really good. But again, it goes. Those initial pictures really did look like infection of some sort. Um, more like C m v honestly than anything else, but, um, but, you know, finding the BVs. Terrific. So you should add this to the literature because you can't find anything like this in the literature. Um, but maybe it will help somebody else in the future. All right, um, going to our last presentation, Dr Herder. All right. I told her all right. Today I have a case entitled Instagram Medicine. Uh, so the presentation is a 35 year old female. She has a history of obesity, and she had an intra gastric balloon placement in the Dominican Republic. And the reason it's called instagram medicine is she found this person on instagram. We had two patients in the same day who both had Dominican Republic instagram balloon placements. Uh, and this was 14 months prior to her coming to our hospital presenting with abdominal pain, reflux, nausea. She was still tolerating some liquids and having normal bowel function on imaging, you can see on the left and the CT scan a very distended stomach on the right. The balloon is seated in the Antrim now, just for reference, because you're most people probably don't see a lot of balloon CTS. This is sort of a normal appearance of a gastric balloon. It is a little bit more distal in the stomach, seated sort of in the Antrim, and there's all this, like fluid and solid material behind it. But it can look like this even in a normal case that's not obstructed. Um, and contrast does pass beyond the balloon, so it's not a complete gastric outlet obstruction. But given that this balloon specifically was made to be removed after 12 months, she had the or bear a 3 65 and it had been over that time and she was having obstructive symptoms. We made the decision to remove the blue, so the first thing we encountered an endoscopy was just a lot of gastric fluid, which is exactly what we expected because the balloon is partially blocking the outlet of the stomach. This is the balloon itself. It is seated down in the Antrim, and we couldn't maneuver the endoscope in a way to get around it, which also sort of implies. Maybe it was in a partially obstructed sort of position. So this is a catheter that comes with the balloon kit, and it's made to deflate the balloon, so you puncture the balloon with a needle, and then you push the catheter into the center of the balloon, remove the needle and then the fluid just flows. You'll note there is methylene blue in the fluid. It's about 600 ccs of blue fluid, and the reason for the blue is that if the balloon prematurely ruptures, the patient will have a change in the color of their urine from the methylene blue, and so they'll know that it ruptured. It turns your urine greenish blue. Um, so the balloon deflates. It kind of turns into this balloon pancake, and then we use another tool that comes with the removal kit, which is this Viper forceps that grasps, and there's little hooks that you can see sink into the plastic there, and then the balloon is removed. Now, even though this is sort of technically simple looking, This is actually one of the more dangerous parts of the balloon, the whole balloon process, because during removal it's very large, and there's a lot of tension that can cause tearing. So this is the balloon outside the body, and then afterwards you want to be sure to inspect and make sure there was no damage. So we don't see any gastric perforation we can clearly document. Everything is patent and we go through the pile Oris. And then the the main areas of risk are the Jew junction, which was clean in this case, and the printer has decided to print and, uh, the upper esophagus. Here there is a shallow Newcastle tear, but nothing too serious. Okay, so after this balloon removal, she had immediate relief of her symptoms, Uh, and really no symptoms from that shallow Tim. Mhm. So learning points just about the intra gastric balloon itself. It's primarily for patients who are obese but maybe don't quite qualify for bariatric surgery. So there's a lot of patients are in the B m I 30 to 35 category who have tried lifestyle attempts and failed. These patients might not be traditionally eligible for bariatric surgery. Patients with a BMI over 35 with comorbidities are eligible for bariatric surgery. Potentially, but not everyone wants bariatric surgery, and this endoscopic solution is a little more appealing to some people. Contraindications are abnormal anatomy, bleeding disorders, pregnancy, substance use disorders, severe liver disease. And there are a few options in the U. S. Right now, or Barra is the one that she had reshaped has this dumbbell to balloon structure. And this is again another mechanism of preventing migration. In the case of premature rupture, if one of the balloon ruptures, the other balloon will stay in the stomach. That's the idea with that one. These are both liquid filled balloons. There's also a gas filled balloon that is ingested as a pill without endoscopy, and the balloon is inflated with gas after ingestion and three balloons of this in the stomach. Mhm. So the outcomes are pretty good with the balloon. Actually, it's a good option for weight loss, uh, in patients who don't want to have surgery and there are many studies of it. I chose this randomized controlled trial balloon versus lifestyle, and the outcome was total body weight loss. In this case, This was a six month balloon placement, and so you can see patients lost about 10% of their total body weight at six months. And the downside, as you would imagine with the balloon, is once you remove the balloon, they can regain weight. And so the red line you can see after six months starts to trend back up. But they still at 12 months, maintained better weight loss than the lifestyle group, so it is semi durable, but not as durable as some of our other interventions. There are potential adverse events. Many patients immediately after placement because they have the balloon in their stomach, have knowledge of vomiting, abdominal pain, reflux, dyspepsia, constipation. All these are usually treated symptomatically. In some cases, UH, that have to balloon has to be removed because the symptoms are too severe. That's about 7% in some studies, up to 15% Serious adverse events are rare, but they there is the right risk of migration or the rupture and sort of migration and the distal obstruction have sent about 1% of patients. There's a very low risk, but a potential for gastric perforation, ulcer, gastric outlet, obstruction, which is sort of what we saw with this balloon. And then during removal, there's a risk of aspiration from all the fluid in the stomach. These patients need to be intubated during removal. There's a risk of esophageal tear, which we saw in this case perforation or bleeding. And there's a very small chance of mortality. This is cited a lot in the gastric balloon literature, but it's a lot of the cases of mortality were in the early studies and in more recent studies. There's in some studies, 0% mortality. So it's a little unclear if this was just sort of a learning curve problem with the balloon, Um, or if it's an ongoing problem, and that is it. Thanks, Nick. I, um uh, so normally the balloon does live down in the Antrim, right? Yeah. So what is it that tips them over to obstruction, like is it just sort of just happens randomly or after a certain amount of time. It just sort of wedges into the pile Oris doing? I think you know, the main mechanism of obstruction would be rupture and migration. In this case, some of the patients I don't Yeah, like you said. I'm not sure what it is that tips them over. It just gets somehow wedged in a position where not enough is getting past it. And then they have vomiting because they always have sort of a degree of partial gastric production. That's sort of the goal of it, and it's usually at the beginning. In her case, it was She felt fine for a while and then got worse, and that was what symptoms over to remove it. So that was the case in Brazil and Rio Private Practice Group. One of the most frequent indications that they had for balloon placement was middle aged women who want to lose some weight before their Childrens wedding. Um, and that was the big cause for balloons, and it would tend to £15 in three months and be very happy the bloom would be taken out. And, uh, everyone would be pleased with the results. Yeah, so s actually sort of a perfect use indication. I don't know if every doctor would be comfortable for that exact indication without a strong obesity reason as well, but it definitely works for short term weight loss. I think a lot of bariatric endoscopy pissed, Um, the balloon is appealing to patients because because it's temporary, Um, but a lot of bariatric endoscopy. It's like to offer another solution, which is the endoscopic sleeve gastro plasticky, which has more weight loss and more durable weight loss. Although it's a little bit of a more involved procedure, it's still not surgery. So that's another good endoscopic option. Do we know the status of, you know, none of this stuff is covered by insurance? Is that on the horizon? As far as I know, As you said right now, none of the endoscopic bariatric procedures are covered by insurance. They're all cash only. Which is why What is driving this medical tourism to the Dominican Republic, where it might be a little cheaper? I don't know when we will have approval for any of this. All right, we are at the hour, so thank you, Nick. Published January 25, 2021 Created by Featured Faculty Jamila Wynter PGY4 Icahn School of Medicine at Mount Sinai Alexandra Livanos, MD, PhD Instructor, Division of Gastroenterology Nicholas Hoerter, MD Advanced Endoscopy Fellow Icahn School of Medicine at Mount Sinai
