Recurrent or refractory small bowel obstruction in postsurgical patients with advanced malignancies poses therapeutic dilemmas. Although some promising results have been achieved as small bowel endoscopic techniques advanced, palliative stent placement is both challenging and complex. Endoscopic ultrasound (EUS)-guided anastomosis using a lumen-apposing metal stent has been recently used during gastroenterostomy to treat benign or malignant gastric outlet obstruction. Data on the outcomes of EUS-guided enterostomy in patients with recurrent small bowel obstruction are lacking, although the technique is applicable throughout the entire gastrointestinal tract. We recently encountered recurrent or refractory small bowel obstruction in two poor surgical candidates. For the first case, we performed EUS-guided enterostomy to treat a recurrent obstruction after conventional stent insertion. The second case underwent EUS-guided transenteric stent placement to treat refractory small bowel obstruction associated with diffuse peritoneal carcinomatosis after failure of a conventional “push” endoscopic procedure.

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is a well-established procedure for the diagnosis of pancreatobiliary disease. Serious complications such as perforation, pancreatitis, hemorrhage, and sepsis are rarely reported. To our knowledge, delayed hemorrhage after EUS-FNA is very rare and hemorrhage from iatrogenic pseudoaneurysm has yet to be reported. We report a case of delayed hemorrhage from gastroduodenal artery pseudoaneurysm, which developed after EUS-FNA of a solid pancreatic lesion. A 68-year-old man presented with tarry stool 10 days after EUS-FNA of a 1.5 cm-sized pancreatic head mass. Abdominal computed tomography showed a 2-cm-sized intensely enhancing round lesion near pancreatic head. EUS-FNA was negative for malignancy. The patient refused admission for further evaluation. Twelve days later, he reported to the emergency room with persistent tarry stool. Angiography showed a gastroduodenal artery pseudoaneurysm. Subsequent coil embolization resulted in successful hemostasis. The patient underwent pylorus-preserving pancreaticoduodenectomy and was diagnosed with stage IIB pancreatic cancer.
Aged ; Aneurysm, False* ; Angiography ; Arteries* ; Diagnosis ; Embolization, Therapeutic ; Emergency Service, Hospital ; Endoscopic Ultrasound-Guided Fine Needle Aspiration* ; Gastrointestinal Hemorrhage ; Head* ; Hemorrhage* ; Hemostasis ; Humans ; Pancreatic Neoplasms ; Pancreaticoduodenectomy ; Pancreatitis ; Sepsis

Ulcerative colitis, an inflammatory bowel disease, often exhibits extra-intestinal manifestations including various dermatological problems. Pyoderma gangrenosum (PG) is a painful ulcerative cutaneous disorder characterized by the development of rapidly enlarging nodules. The lesion may become aggravated when ulcerative colitis is active, and it commonly affects the extensor surfaces of the lower extremities but rarely the upper extremities, face, periauricular area, anterior chest, back, or buttocks. We encountered a rare case of PG of the chest wall near the left breast, on the face and pretibial area of a male patient with ulcerative colitis. He had not undergone breast surgery and had no history of trauma. The lesion and symptoms were successfully treated by steroid and mesalazine; there was no need for surgery or more potent drugs.

Small bowel obstructions (SBOs) that develop for various reasons often require prompt medical treatment. Migration of a gastric bezoar (indigestible foreign material that has accumulated in the stomach) is a rare cause of SBO. Treatment of a symptomatic SBO caused by a bezoar requires a multidisciplinary approach that considers the patient’s physical status and comorbidities and the bezoar volume, location, and pathology. Although surgery is the treatment of choice, endoscopic treatments such as fragmentation and retrieval may serve as alternatives. We present the first case of resolution of a large phytobezoar via mechanical compression after covered metal stent insertion, followed by stent retrieval, in a patient with a symptomatic SBO that persisted even after two sessions of push-endoscopic fragmentation.

Ulcerative colitis, an inflammatory bowel disease, often exhibits extra-intestinal manifestations including various dermatological problems. Pyoderma gangrenosum (PG) is a painful ulcerative cutaneous disorder characterized by the development of rapidly enlarging nodules. The lesion may become aggravated when ulcerative colitis is active, and it commonly affects the extensor surfaces of the lower extremities but rarely the upper extremities, face, periauricular area, anterior chest, back, or buttocks. We encountered a rare case of PG of the chest wall near the left breast, on the face and pretibial area of a male patient with ulcerative colitis. He had not undergone breast surgery and had no history of trauma. The lesion and symptoms were successfully treated by steroid and mesalazine; there was no need for surgery or more potent drugs.

Small bowel obstructions (SBOs) that develop for various reasons often require prompt medical treatment. Migration of a gastric bezoar (indigestible foreign material that has accumulated in the stomach) is a rare cause of SBO. Treatment of a symptomatic SBO caused by a bezoar requires a multidisciplinary approach that considers the patient’s physical status and comorbidities and the bezoar volume, location, and pathology. Although surgery is the treatment of choice, endoscopic treatments such as fragmentation and retrieval may serve as alternatives. We present the first case of resolution of a large phytobezoar via mechanical compression after covered metal stent insertion, followed by stent retrieval, in a patient with a symptomatic SBO that persisted even after two sessions of push-endoscopic fragmentation.

After failed removal of common bile duct or intrahepatic bile duct (IHD) stones by endoscopic retrograde cholangiopancreatography (ERCP), percutaneous lithotripsy is well-known as an effective procedure. However, it is time-consuming because multiple sessions of transhepatic tract dilatation are required. Endoscopic ultrasound (EUS)-guided choledochoduodenostomy (CDS) has been recently used to approach IHD to remove difficult bile duct stones. We recently experienced EUS-guided CDS performed with metal stent. Common bile duct or IHD stones were removed by retrieval accessories after initial failed or inadequate ERCP in three patients. Serious complications including bleeding, infection, and perforation were not noted. The duration of hospital stay from EUS-guided procedure to discharge ranged from 10 to 14 days. Although this result is interim and ongoing, it suggests that EUS-guided CDS might be an effective and safe procedure after failed ERCP to remove difficult bile duct stones through the tract.

Endoscopic ultrasound (EUS)-guided gallbladder (GB) drainage has recently emerged as a more feasible treatment than percutaneous transhepatic GB drainage for acute cholecystitis. In EUS-guided cholecystostomies in patients with distended GBs without pericholecystic inflammation or prominent wall thickening, a needle puncture with tract dilatation is often difficult. Guidewires may slip during the insertion of thin and flexible drainage catheters, which can also cause the body portion of the catheter to be unexpectedly situated and prolonged between the GB and intestines because the non-inflamed distended GB is fluctuant. Upon fluoroscopic examination during the procedure, the position of the abnormally coiled catheter may appear to be correct in patients with a distended stomach. We experienced such an adverse event with fatal bile peritonitis in a patient with GB distension suggestive of malignant bile duct stricture. Fatal bile peritonitis then occurred. Therefore, the endoscopist should confirm the indications for cholecystostomy and determine whether a distended GB is a secondary change or acute cholecystitis.

A previously healthy 44-year-old woman who was diagnosed as having dermatomyositis suddenly developed severe dyspnea while being in the state of improved condition of muscle weakness. Interstitial lung disease was found on high resolution computed tomography (HRCT). In spite of the treatment with the immune-modulating agent (high dose steroid, cyclophosphamide, immunoglubulin and cyclosporine), her condition deteriorated further and rapidly, leading to death. More intensive agent such as FK506 would be necessary in those cases of dermatomyositis-related interstitial lung disease that have poor prognostic factors.
Adult ; Cyclophosphamide ; Dermatomyositis* ; Dyspnea ; Female ; Humans ; Lung Diseases, Interstitial* ; Muscle Weakness ; Tacrolimus

A mature teratoma is a tumor composed of normal derivatives of all three germ layers, and usually occurs in ovaries, testes, or mediastinum. Mature teratoma of the gastrointestinal tract occurs less frequently, and case reports of primary mature teratoma of the rectum have not been published much. Here, we report a 65-year-old woman patient presented with lower abdominal discomfort. Colonoscopy revealed a pedunculated polypoid tumor arising from the rectum with hairs on its surface, and endoscopic ultrasound revealed an exophytic pattern bulging from the serosa. The tumor was removed surgically and confirmed histologically as a benign, primary mature teratoma of the rectum.
Aged ; Colonoscopy ; Female ; Gastrointestinal Tract ; Germ Layers ; Hair ; Humans ; Mediastinum ; Ovary ; Rectum* ; Serous Membrane ; Teratoma* ; Testis ; Ultrasonography