Video Endoscopy Conference 9/11/20 Play Pause Volume Quality 1080P 720P 576P Fullscreen Captions Transcript Chapters Slides Endoscopy Conference 9/11/20 Overview Three cases are presented here: • 01:33 – Gastric Polyps in FAP • 20:20 – Kaposi Sarcoma in GI Tract • 34:50 – Gallstone Ileus welcome to everybody. And good morning. This is our, uh, start of the school year as has been mentioned. Um, welcome to our G I fellowship applicants. Um, this is the Jerry Way endoscopy conference. Just by way of a little background jerry way. If you don't know who he is, you You soon will learn Just spending the day here. Uh, Jerry is one of the forefathers of colonoscopy and particularly holla pic to me as a way of colon cancer prevention. And he has been a stalwart here at Sinai for about 50 years, and he recently retired. He started this video case conference over 30 years ago and every Friday morning for the past several decades, uh, he would bring interesting cases to show g i and surgical colleagues. Uh, and it's just evolved over the years, and now it's one of our favorite, uh, events during the week. Um, we have our consult. Fellows are advanced. Nasty fellows, uh, surgeons, pathologists, radiologists bring interesting cases for education and discussion and debate. Excuse me. Excuse me. And, uh, So, um, so we're excited to kick things off. Um, So I will turn it over to, uh you Young and Zoe. I'll, uh, let you guys start with the presentation. I think everyone's connected, and, as you all know, feel free to chime in with comments and questions. Hi, everyone. I hope you guys can see my screen. I'm Yu Yang. I'm one of the first year fellows. I'm excited to share a case that I saw on Consults last week. Um, you'll have to forgive me just because the video of fortunately did it save in probation. But I do have some good images. So our case begins with a 56 year old female. She has a history of familial adenoma. Is Paul opposes status? Post total Proctor Proctor collected me with an Elias a Me back in 2012 who presented with the fatigue and shortness of breath for one week. She actually had an endoscopy back in March of 2018 that demonstrated multiple gastric polyps with evidence of prior bleeding, and at that time, a normal Guantanamo. She had an Elias copy that was essentially normal and showed one polyp at her stillness site, Um, on review of systems and interview with the patient. She just reports, noting occasionally bright red blood in her Osumi bag that the color of the output and the amount of output was still the same. And it was brown, her hemoglobin. Our arrival was 6.3 from a baseline in the time. So after appropriate transfusion, we took it to the end of sweet and perform an upper endoscopy. And Elias, Um so here are some of the images that we captured during our upper endoscopy. Um, you can see that the entire stomach, including the proximal stomach, body fungus and central area were covered with these. Like innumerable friable polyps. They ranged in size from five millimeters to greater than 3.5 centimeters. Um, in addition to these individual polyps, you can see that there are essentially these, like mounds of polyps. It's really hard to actually distinguish the polyps. Um, individually and, uh, one might say they resemble a carpet. Um, we also saw a broad based polyp in the duodenum, which was visualized at 10 o'clock. So through this endoscopy, we established that the likely ideology of her ongoing bleeding and anemia were from these multiple gastric polyps just because some of them were spontaneously bleeding and bruising. But the next step in sort of. Her management clinical course was What were these polyps? Um, what should be done about them? Because, um, because they were spontaneous. Losing there were so extensive we didn't end up doing any polyp economies. So we took biopsies from the gastric and duodenal polyps. Um, and they actually came back indefinite for dysplasia, and we'll talk a little bit more about what that means. Um, and our patient ended up being transfused a total of two of four units of packed red blood cells with resolution of her shortness of breath and fatigue. Um, and she was discharged home. So I thought this would be a good time to review gastric polyps, specifically in, um f a p just because there is a spectrum of the type of gastro policy we see and require different management. So the a S g e actually, just very recently, in May of this year, it came out with new guidelines on the role of endoscopy and familial. Analyst Paul opposes syndromes, has a review. F A P is a complex entity. It includes F AP itself attenuated F A P and um Mut yh Associated policy poses patients with F A P are at risk for colorectal cancer but also carry a risk. Um, for extra colonic cancer as well, including cancers in the duodenum, thyroid HIPAA to blast oma. That's my tumors and stomach cancer, you'll notice, is not actually all that common funded Grandpa looks are the most common types of gastric polyps that you'll see in patients with F A P. They have a prevalence of up to 90%. Dysplasia can develop and funded gland polyps in patients with F A P. Unlike the sporadic funding gland polyps that you see associated with PP, I use um in one case series, they actually found that dysplasia was in up to 42% of patients and that it was more likely with larger polyps where than one centimeter like in our patients and increased severity of duodenal polyp Asus Um, gastric adenomas are less common than, um in patients with F A P in the Western and Western countries. Compared to Eastern countries, the problems in the US and Europe is about 10% whereas in Asia it's about 36 to 50%. Just because there is a higher incidence of gastric cancer in that region of the world. Adenomas can occur anywhere, but typically, um, they occur more commonly in the Antrim and appear Cecil Um, and they look kind of subtle with avila form red appearance. Um, and or sometimes, although if they occur in the fondas, are difficult to differentiate from funded gland polyps and lastly, gastric adenocarcinoma. They also can occur anywhere in the stomach, and they can be multi centric and attack Cronus. Um, it's thought to be fairly rare in the Western population, But a recent case series demonstrated that gastric, adenocarcinoma and F A P patients in the U. S has actually increased with an overall incidence of 1.3%. Um, and interesting they these authors in that same case series did, um, interval, uh, sort of time to interval of diagnosis. And basically the average time from initial collected me to the diagnosis. Gastric cancer was an average of 23 years. Um, so what did the HSG recommend? They recommend 3 to 6 month intervals. Surveillance E g. D. With aggressive polyps sampling and endoscopic de bulking. Especially these gastric Paul opposes amounts that we saw in our patient because they found more stage one cancer is using these protocols. They recommend evaluation of all polyps, including funded gland polyps with random biopsy sampling and complete resection of polyps greater one centimeter because of the high risk of adenomas and Antrel polyps, they recommend that all Antrel polish if you removed, regardless of size. Um, and they also listed some endoscopic risk factors are associated with malignancy, including carpeted funded gland polyps and mounds of gastric polyps that are in the fund is, um, body, Um, and lastly, for patients who have undergone polyps and adenomas that harbor advanced histological features or those who fail endoscopic management in terms of the bulking, they recommend, uh, evaluation with an experienced surgeon. Um, recently, a new endoscopic entity has been identified. That is potentially worrisome impatience with F A P. This is the white mucosal patch. It is a well demarcated area of mucosa where it's actually normal. Um, mucosal and vascular patterns that is surrounded by, um, a carpet of funding grand polyps. The white whitish area that you see here is easily distinguishable from the reddish appearance of the polyps, Uh, funded gland polyps in the stomach, especially when criminal and endoscopy is used. The white mucosal patch lesion is usually a bit elevated, usually a Paris classification 0 to 2 a. Um, and I found this case review in G i E. That was published back in 2018 that demonstrated that, um, patients with white mucosal patches were more likely than patients without non white mucosal patches to have high risk endoscopic features. The carpeting of proximate polyp posters that we talked about and these polyp point now Table one here demonstrates the higher prevalence of high risk pathologic features both within the white mucosal patch and um outside of the white mucosal patch. And what the authors point out most alarmingly is that two of the 14 patients with white mucosal patches had, um proximal gastric cancer with a prevalence of, um 14% which is much higher than the overall prevalence of 1% in our overall um, U S population. So the authors postulate that if you see these white mucosal patches specifically in the in the proximal stomach of A S, a p patient, it's a feature that can be potentially associated with gastric cancer. Um, so just some take home points. Um, gastric polyps and F a P includes funded gland polyps, which are the most common, up to 50% of which can be associated with dysplasia, adenomas and gastric admiral carcinomas are much rarer. The S G recommends 3 to 6 months e g d surveillance for biopsy and be bulking of all polyps greater than one centimeter. Some of the worrisome endoscopic features are associated with malignancy, including carpeted funded gland polyps, definitely concentrated amounts of gastric polyps. What mucosal patches. And lastly. And this is what happened with our patient is a surgery evaluation for patients who harbor either histological features that are considered high risk or fail endoscopic management in terms of, uh, the bulking or, uh, or that it's so extensive that it's impossible to survey. All right, that's it. Thank you. Thank you so much. That was fantastic. So much so much that we can talk about here. Um, it's a little interesting and I'm going to ask Steve. It's cool. It's to comment in a second. I'm very surprised that those s G recommendations they seem quite aggressive, I think in our practice here, um, we typically leave gastric polyps alone, and it's usually more the duodenal adenomas that are the big issue that we're dealing with in these patients in this patient population. Um, and I can probably count on one hand how many times I've seen a gastric cancer and an f a p patient. But, Steve, we love your input on this. And should we be more aggressive in our endoscopic surveillance and management of these patients? Yeah. Thanks, Chris. Um, let me start by first acknowledging the wonderful virtual background that Zoe put up. I think it's really it's so creative and so clever. Um, I guess the pink colon reflects the fact that all of our fellows are women this year. I'm not sure. Um, at any rate, casa its mucosa got it. Okay. And also and you, you did an incredible job. Tell you for the first talk of the year, Uh, it was really perfect. And you highlighted all the really important top issues. Chris is right. I think these recommendations are very aggressive. Um, it takes many, many, many years for people who have all of these gastric polyps for them to ever get gastric cancer, and somehow surveying them every 3 to 6 months seems kind of overkill. You know it's really easy to write these guidelines, but in reality you look at that stomach. You you can't identify polyps that are a centimeter or a centimeter and a half or it's just carpeting, and it's very, very treacherous to manage these patients. That white mucosal patch sign was really a break through a couple of years ago. If you see that, that's an area where you may be more likely to find high grade dysplasia, so you want to target your biopsies or politics. Um, is there, but most of the time you don't even see that a question I have about this case is that you described using that there were polyps in the Antrim. Now the Antrim is almost always spared of polyps in F A P patients. If you see a polyp in the interim, it's usually single, and it's usually an adenoma, not a not a funding Rampolla but an adenoma. And the pathology report said hyper plastic inflammatory polyps. It didn't say funded gland polyps, and I'm wondering whether the diagnosis on this patient is juvenile. Paul opposes altogether, because with juvenile Peloponnesus, you can find polyps throughout the stomach, not just in the in the proximal stomach like you see with a P. So has this patient been genetically tested? Does she have a germline a PC mutation? Do we know that? Um, actually, I she came to Sinai with diagnosis f f p. So I don't believe she was journaling tested when I went back into the chart, the first thing I would do and the first thing I would do because the other thing is juvenile Peloponnesus, if that's what this is. Those polyps are very friable like you showed, and they bleed. And these people with juvenile Peloponnesus walk around all the time with iron deficiency anemia because those policies whose blood all the time uh, f a p patients, Even with the carpeting in the proximal stomach, the adenomas don't bleed as much. Not the autonomous the fund. England polyps don't bleed as much as the juvenile polyps. So the first thing we have to do is confirm the diagnosis. Here she needs genetic testing if she hasn't had it already, because this might well be juvenile Peloponnesus syndrome, which changes things. Um, so that's one thing I don't know is I don't see any of the pathologist on the on the line. Um, no. I wonder if you can comment on the distribution of polyps in the stomach comparing juvenile Peloponnesus and F A p. You're muted gnome. Can you on mute? Maybe not. Maybe in here. Okay. At any rate, um, those are my comments and the last thing I'll leave you with and you young highlighted this. Um, Although gastric adenocarcinoma is really a dreaded consequence of f A p, it's still extremely rare and as scary as the stomachs. Look, we have to be careful not to overreact because most of these people, as you said, have already had their collective me. Um, and if you then consider taking out their stomach and doing a really what becomes very often a total gastrectomy, their quality of life is horrible. So it's a real, real tricky decision to make to do anything other than just sort of endoscopic surveillance on these. So we had a case, Steve, I think you were involved. It was a patient patient who already had his collect to me. We saw him for duodenal polyp Asus, and he had a very high risk lesion that was not endoscopic Lee. Respectable and almost just sort of. Incidentally, on the way out, I saw a small little area at the cardiology junction which, you know, it looked like a savage itis that took a biopsy. And it came back his gastric cancer, and Nicky was able to do. And so he needed a Whipple for his duodenum. He already had to collect me. And based on the location of this gastric cancer, he would have needed a total gastrectomy as well. And if we ever presented the case, But the key was able to do an SD respect the proximal gastric lesion. And then he went on to have his Whipple. At least he was able to save his stomach for the time being. So I mean, it's really just amazing. That was an amazing case. It was amazing that you saw that little bump, that it turned out to be cancer and that it was locally respectable, that it's reportable. Um, but that's that's really a great win. Um, I don't know if No, No, um, do you hear us? All right. Maybe we can just sign. Wow. All right, great case. Thank you again. Uh, and, uh, more to follow I'm sorry. I'm commuted. Oh, six. Yeah. You have a one minute commentary window. I have no comment. I don't know which case you're talking about, but it sounds amazing. No. A quick question to, you know, in the stomach of an f a P patient versus the stomach of a juvenile. Paul opposes. Patient is the Antrim spare. The Antrim is almost always spared in F A P, but what does the Antrim look like in juvenile Peloponnesus syndrome? I don't know that there's any particular distribution, but I'd have to look that up. It's not like we see it very often, and and it's really just a handful of cases that we've seen. But I'm not aware it has the same kind of proximal distribution. And if you if you report a gastric polyp as being hyper plastic or inflammatory, that's that's different from thunder gland polyp, is it not? Oh, yeah. So it's really different. Yeah, So you see, the histology here is is taking us down the road of juvenile Peloponnesus, not F a P. So it's really important to know what it would look more like an inflammatory type of polyp and usually only if we know the patient's history. Can we tell you? Well, you know, that looks identical to a juvenile Pollo. Yeah. Okay, so I'm going back to being muted. Thank you. Cases, Joey, Miss Pink Colon. You are All right, You Do you mind sharing your screen again? Thank you so much. Um, so Good morning, everybody. I'm Zoe. I am one of the third year fellows and, um, one of the chief fellas, I'll talk to you all this morning with you, Kira. I am going to talk about a case that we actually did a few weeks ago when I was covering the impatient service. So next slide. So this 65 year old gentleman, it's actually Jim Mila's patient. But I don't think she's here this morning. I think she might be on vacation. This is a 65 year old gentleman. He has a history of end stage renal disease from hypertension and diabetes. He had a deceased donor kidney transplant in 2015, for which he's been on the ladder. Steps, cellcept and prednisone. Low dose, pregnant, Only about five a day. Hypertension, diabetes. As I mentioned, BPH who came to Sinai after being hospitalized at another hospital for several weeks with fever, anorexia and incidental weight loss. He had no G I symptoms, no abdominal pain, diarrhea, nausea, vomiting, black or bloody stool. And when he got here, Transplanted was consulted. Reno was consulted. He had a very extensive infectious work up, which was only positive for J. C Pyrenean and H H B A fiery MIA, both pretty low grade and both which were thought to reflect excessive immuno suppression. Um, rather than necessarily a source of infection for the I. D consultants. Um, and we're unclear clinical significance. Uh, he had a bone marrow biopsy. It showed some immature forms. It wasn't sort of a slam dunk. They thought it might be consistent with immuno suppression versus MDs and plan to repeat it later. Um, and the got several imaging studies, including a CT, abdomen, pelvis and an MRI bring the MRI because of the JC virus. Nothing was clear, and he continued to spike fevers into the 100 to 103 range. So, g, I was consulted to do an endoscopy to rule out any occult malignancy or opportunistic infection. Um, and when I came, I was actually just scoping and I was kind of surprised to hear this because I had never previously sculpt just for a fever of unknown origin. Next slide. So this is the video. The quality of the video is not excellent, but basically, what you can see is when we went into the stomach, we saw multiple sort of erythema tous almost delicious, uh, lesions that were extremely friable, um, and distributed really throughout the entire stomach. There were not dense patches or extremely large versions of them, but they were sort of certainly abnormal and made us worried about particular opportunistic infections we can talk about in a moment. So if you can go to the next slide, Actually, the photos are significantly better than the video. You can see these, uh, sort of Paula coid, Very friable lesions red. Um, but also actually, on the actual scope appeared a little bit also more violent in color. So we took extensive samples, um, and to go to the next image is the pathology was actually consistent with Kaposi's sarcoma, which is what we had postulated when we were doing the endoscopy. Um, and this was not surprising to us in the sense that he had this HB h h h b eight Kyrenia and also was immuno suppressed. But he was immuno suppressed in the setting of a renal transplant, which, um, is actually not a common, uh, scenario for developing composing sarcoma. We really think about it much more in the context of immuno suppression in the setting of HIV. So from a clinical course perspective, they modified his, uh, you know, therapy throughout, actually his hospitalization. He ended up being changed to Sierra Lima and continued his lotus prednisone. He was discharged with the plan to follow up Assad oncology to discuss management of chaos, and he hasn't had that appointment yet. So I thought this would be a good opportunity to discuss composes sarcoma in the GI tract. And as I mentioned, there's really not a lot of data on cases in immuno suppression from medication in the setting of post transplant, for example, most of the cases and studies have been performed in the context of HIV, and actually, we're writing this case up because it was so interesting and surprising. So I'm going to review a paper that was published in Plus 1, 2000 and 12 that looked at clinical predictive factors in the diagnosis of gastrointestinal composes, sarcoma and endoscopic severity. Because, for example, in this case the patient had no cutaneous lesions and we had no G I symptoms. So it was really only in the context of doing a really thorough Fuso work up that we ended up even doing an endoscopy. So, um, the background and objectives. So just to give a little bit of background on composing sarcoma, it's a rare malignancy. It's associated with H H V eight. It involves the lymphatic and blood vessels most commonly presents as these large violation large, just like a small violations lesions on the skin but can have visceral involvement, including the G I tract. The higher risk is immuno suppressants, and the person prevalence is particularly high in HIV patients and patients with chaos of the GI tract might have no G I symptoms or skin lesions. So the objective of this study was to identify clinical predictors of severe chaos on endoscopy in patients with and without GI symptoms. So this is a retrospective study of over 1000 patients with HIV who had undergone endoscopy at a single major medical Center in Tokyo between 3 4000 and nine. The indications for endoscopy CD four count a week before the sculpt HIV viral load within a month of the scope, history of treatment with the antiretrovirals and HIV infection route were all reviewed. Um, and abnormal lesions seen on upper or lower endoscopy were biopsied. And they were, uh, the severity was determined based on the size of the lesion. The alteration in the number of overall lesions and they defined gastrointestinal chaos is the presence of proliferating spindle cells on Asian be standing. So this is actually lesions from their paper. I just wanted to give an example of sort of the range of different endoscopic findings that you can see in chaos. I've actually seen endoscopic chaos before gastrointestinal chaos before it looks more like, uh, image. In my prior experience that looked more like image. See, um, and if you click one more young, I just put up a picture of our patient to compare the findings. Just so you can see, there really is a very wide range of endoscopic appearances. So if you have any suspicion is extremely important to perform multiple biopsies if you can get a good tissue sample next slide, so the results. The median age is 44. Almost all of the patients were male. Um, most patients had a CD, four count of 239 in a viral load that was less than a say in the majority had received antiretroviral therapy. Only 33 patients of this over 1000 patient cohort actually were diagnosed with gastrointestinal chaos. 78.8% of them had no G I symptoms at all, and only 24.2% had cutaneous lesions. So really important to have a high suspicion in there. You know, very in analysis. The only predictive factors that were associated with gastric gastrointestinal chaos were patients who had gotten HIV through MSN transmission patients with very low CD four counts or HIV viral loads, patients who had never had antiretroviral therapy and as sort of approximately being, particularly in, you know, and those who had cutaneous chaos and then when they performed the multi variant analyses. Cutaneous chaos was the only clinical, independent clinical factor related to GI chaos and patients without with and without symptoms and in patients who had no skin lesions, MSN transmission and a low CD four were the only independent clinical predictors. I made this little pie charges to give you a sense because they did both upper and lower endoscopy, where the larger proportion of patients had their lesions and really stomach and duodenum were the largest range of patients. But patients did have lesions throughout the entire GI tract, including esophagus, t I colon and rectum. So this is just to give a sense. This is a large table. I actually hate saying This is a table. It's kind of hard to see but to give you the overall sense. But basically the most important finding is that bulky tumors were associated with very low CD. Four counts and multiple lesions were associated with very high HIV viral loads. And there was no significant difference in the presence of skin lesions in patients who have mild or severe chaos on endoscopy. And I think this sort of goes back to the overall point is, the more immuno suppressed you you are, the more likely you are to have a more severe and to stop it presentation of chaos. So just a big takeaways most patients who have gastrointestinal ks don't have GI symptoms. They do not have to have cutaneous lesions to have GI involvement, the risk of severe G i. G. I. K. S increases with increasing immuno suppression. And basically, if a patient is immuno suppressed for any reason, not just in the setting of HIV and systemically ill with an un revealing work up, you should consider an endoscopic evaluation and having done this literature, you know, I would have said had we not found anything on the upper endoscopy, it would have been worth doing a colon as well, because these lesions can be anywhere throughout the G I tract. That's it. Thank you, Union. Your incredible power Point helper. I really appreciate it, Zoey. One question. You know, we know these lesions can be Vastar vascular and can bleed easily. Is there any concern? Are reports of patients having severe bleeding after a biopsy? I didn't find any and, um uh, Davis is shaking his head. No. And I would refer to him as the endoscopic expert on this more than I am. But they didn't They used. But we did not have such significant bleeding. I did this case with bridge in, um, there was really not a lot of worries. They used less than, for example, when we take biopsies of tumors like in the esophagus or in the stomach, that really, really bleed, that I always get worried we should like the most right or something like that. But, um, they did not leave that much. I'd have to do more extensive literature review about posting, biopsy, bleeding. And then I may have missed that. I apologize if I did. Is there any correlation with prognosis Is if you have GI composes in these immuno suppressed or HIV patients, in other words, are they more likely to have a more disastrous disease course or complications? It's in HIV patients. The development of chaos reflects an extremely immuno suppressed state and is associated with a high, higher viral load. So I think these patients are overall more systemically ill with more severe courses. There are really not a lot of cases describing ks or G. I. K s and patients who are on immuno suppression in the setting of other disease courses like this was in the setting of being immuno suppressed from a kidney transplant And so that's why we're actually publishing, attempting to publish a case report on this. Because it's so, uh huh. The description of it in the literature has such limited supply because it is really interesting. What? What is his outcome going to be? There is also this question him about dvf MDs versus was this just like an abnormal bone marrow transplant? Because he was on such high levels of immuno suppression. Um, and I wonder, sort of What? The optimism. Sure, we'll smoke him again. I think he's actually following up with Dr McAndrew and Clinic in a few weeks. I'm sure we'll scope him again once he receives treatment to sort of see what's going on. Very interested to see what his courses in terms of fevers, um, and poor Pio and take once his immuno suppression has been modified. And then once we treat the chaos. So this is more of a common than a question. So it's actually very interesting. Uh, you alluded to this just now. We don't really understand what the correlates of, uh you know, some of these opportunistic either infections or lesions in the gut is because the G I tract does get, you know, very, very profoundly depleted of CD four cells very early in the course of HIV infection within the first two or three weeks of infection. And yet these opportunistic or, you know, inflammatory legions. They occur much later on in the course of HIV illness, when immune suppression is, uh is more profound. And it correlates, actually, with a systemic loss of CD four cells below certain thresholds, like, you know, 200 150. So what changes in the mucosa at that level? Are there some innate cells that change? Are there is there a difference in trafficking to the mucosa? Because the bone marrow is so profoundly suppressed. So you turn off the tap. These are all I think, questions that even to this day within HIV have been unanswered. And I would just, you know, sort of use this opportunity to, uh, just mentioned to anyone that if you're seeing patients like this, which are, you know, rare now, I think consider these these sorts of questions that we still don't understand why they're having, uh, these advanced lesions on the mucosa, and that would actually be in advance of people to try to figure out, You know, there are technologies now be able to at least attempt to do that. Uh, a great case. Thank you. I would just I would just point out that if you look carefully at the endoscopic photos that you showed these violations lesions in chaos, they have sort of a giraffe skin like appearance. Unlike other little red bumps that you might find in the stomach occasionally, if you look really closely, it looks a little like Jurassic. And, um so that's another tip off that it's chaos. You know, as as someone who really grew up at the beginning of the AIDS epidemic, we would see ks patients four or five times a week. It was extremely common. Uh, before we knew, uh, enough about what was causing AIDS. Steve, Is that your descriptor, or is that an established descriptor? It's mine. It's mine. But I haven't published it. Maybe it should. That was sort of what I was going to say to the chaos used to. We used to see this all the time, Um, and and Chris, to answer your question, you know, the prognosis had to do with the underlying HIV immuno suppression. All right. Thank you so much, Zoe. A fascinating case. Great discussion. Um, we have time for one more. It looks like. And we're gonna turn it over to Nick, our advanced endoscopy fellow. Alright, Thank you. Sorry for the lack of video. I will figure out the technology issues for next week, but I do have a presentation, so I'll share my screen. Okay. So again, my name is Nick Herder and the advanced Endoscopy fellow here at Sinai. And I'm going to present the case of Gall Stone alias Mhm. The patient was a 55 year old male presented. He has a history of Crohn's disease status Post collect me with and Elias to me remotely. Also remote self inflicted gunshot wound with cognitive impairment, a few other medical comorbidities coronary artery disease, hypertension, and, uh, two years ago, he had colon cystitis, an outside hospital, and had a cold system YouTube that was subsequently removed. He presented initially with hypertension abdominal pain in the e. D. He was actually hypertensive in federal and septic, requiring pressers. He was noted to have some abdominal tenderness on labs. He had a leukocyte Asus pretty severe. AKI um, relatively unremarkable LFTs on imaging. He had a few findings, so he had dilated loops of bowel. You can see air fluid levels on the left consistent with an obstruction. He had new mobile Leah, you can see in the left image air in the left, intra paddock ducks and on the right image air in the gallbladder. I'm not sure if there's a fancy medical word for that. I would propose this ridiculous word here pneumoconiosis to, uh, and than most dramatically, he had a stone obstructing his Elias me. So that one kind of is a giveaway. And so he was diagnosed with gallstones. Alias, given the location of the stone. Since it was so close to the OSCE to me, rather than proceeding with standard management, which would have been surgery, uh, we elected to take him for endoscopy to see if we could potentially manage this issue. Um, a little lesson. Basically. So have an endoscopy. Video videos. Okay. So immediately upon entering the Ostuni, uh, there was this impacted stone, and you could actually feel it. You could palpate it with your finger. And you can see it is including essentially the whole Lumen as expected, and we couldn't really There was no way to get around it with the scope or really pass any devices passed it. And so we elected to try to break it up with electro hydraulic with the trip. See, which is the device that you will see in the lower left here. And, uh, this is, uh, sort of extensive video of this Just because it's so satisfying to see the stone break up with the h L. That I left it kind of uncut for a few minutes and we'll just see this stone progressively explode as I explained how HL works. But essentially, the device has two electrodes and there's a high voltage spark that's produced between the electrodes. It's meant to be used in a fluid medium, so you can see continuous irrigation here with saline. Uh, the sailing also helps with conductivity between the electrodes. Um, and the spark creates a shockwave in the fluid because the fluid rapidly expands and the shockwave basically causes mechanical destruction of the stone. And the idea is, it's not perfect technique here, but you're supposed to hold it like just off of the film and then apply energy and the shock wave breaks it up. The probe is designed to fit through Colin Jost API scope, which is at 1.2 millimeter channel, so it's very fragile. As you can see, it's kind of tiny relative to the stone. So if you hold it up to close it and, uh, it kind of breaks the probe and sometimes you have to go through a couple probes. If the stone is really large, this one, you can see it's the stone is fragmenting beautifully. Uh, there's pieces flying everywhere. Um, and very soon we will have big break that won't get us through this. Think it's about to happen. So it's going to clear up enough here to get through. And you can see this is the mucosa in the ass to me. Um, as you recall, he had a remote history of this Crohn's diagnosis and wasn't on any therapy. And it became immediately apparent that he had very severe disease recurrent at the S to me here. And you can see deep alterations, um, inflamed mucosa. And then this area is very tight as well. Just looks sort of like an inflammatory stricture. And this is part of the reason that contributed to the stone getting stuck because it was just so narrow at the exit. So this is just showing that. And then here is the major piece of the stone. But there are little pieces floating all around, and this was still big enough. Although it's now free floating in this part of the women, it was still big enough to obstruct the exit to the OSCE to me. So we elected to remove it. Scare with the Roth Matt. And we first it from me asking me here there is still tight coming out, and there it is, the culprit. Mhm. All right, Very cool. So he actually did great after that, that he had returned ghasemi function. Uh, pretty much the day after improvement of Lucas psychosis and his a k I and I was so happy with the result, everything was great. And then he actually got a little worse from a second problem. He started having feculent output from his prior coexist Ostuni site, and essentially he had developed a fistula between the bowel, the gallbladder and the skin. So it's kind of like an interior cutaneous fistula and had to go back to the O. R. For that reason. So, uh, he had an austere revision, given the active Crohn's there, uh, takedown of that interest, cutaneous fistula. And the closest ectomy which would prevent recurrence of golf. So millions in the future. But then he did great post operatively. So we'll go through just a couple teaching points. Nicholson is pretty rare. Yeah, sure. We have about a minute before we have to wrap. Okay. One minute. I won't go nuts about talking about Leo. Regular interesting guy. Okay, so the Triad is an imaging diagnosis for golf Cornelius memorabilia and has some obstruction. Visualize stone. The reason for the new mobile Leah is in order for a stone that's large enough to obstruct the loom in. To get out of the gallbladder, you essentially have to have the fistula between the gallbladder and the intestine. Which results in the new mobile. Yah. So that's that finding, um, e h l uh, we talked about here. We usually use it for difficult to remove bile stones occasionally pancreatic duct stones. And, uh, as I described. It's usually used through Kalandia Skopje. It has been shown to have good efficacy, with about 88% doctor clearance in a large meta analysis. And it has reduced rates of cholangitis and mortality compared to just standing alone in the case of recurrent stones or difficult stones that can't be removed by other methods. And that's that outstanding. That looks like fun. It's never, never it never gets old. When your breakup stones removed, big story was so satisfying. It's a little weird. I don't know if that was your first DHL case this year, but it's a little odd that it occurred outside of the bile duct. But then again, true, that wasn't the standard approach. So, Nick, why, Why not? Uh, why did you use electric shock rather than mechanical with the trip? See, when it was so easily so we did Yes. That is a great question. We we thought about you know what devices we have available. And then I think the key in that case was that we couldn't really get around it. We didn't even really try too hard, but we would have had to get the mechanical that the trip for basket sort of around the stone and just because it occluded the entire loom in. I think it would have been challenging technically to use that device. So luckily, the HL doesn't require you to get behind the stones. You just sit right in front of it. So it was really amenable to that therapy. I also hope to pull it out manually. But the structure at the awesome decide prevented that from happening, so we had to break it up. And if you look at the data regarding mechanical with a trip see versus E H L for removal of large stones, E H l or laser litter trip Laser Luther trip see wins out every time for shorter procedure times fewer number of endoscopic sessions. More than one is needed. And it's just technically easier and certainly more fun. Um, very mostly it's more effective. Love it. Mm. Published December 4, 2020 Created by Featured Faculty Yuying Luo PGY4 Icahn School of Medicine at Mount Sinai Zoë Gottlieb, MD PGY6 Icahn School of Medicine at Mount Sinai Nicholas Hoerter, MD Advanced Endoscopy Fellow Icahn School of Medicine at Mount Sinai
