Clinical Case Summary

An 81 year-old male, with no relevant medical history, presented to the emergency department with hematemesis, hemodynamic instability and hemoglobin of 4.5 g/dL. Upper gastrointestinal endoscopy (UGE) revealed 30 mm excavated gastric ulcer at the incisura angularis, with a visible vessel (Forrest IIa). Initial attempt using over-the-scope clip (OTSC) failed due to inability to pass the upper esophageal sphincter despite multiple expert attempts. Subsequent therapy with epinephrine and two through-the-scope (TTS) clips achieved initial hemostasis. However, patient experienced three rebleeding episodes in the following days, requiring repeated endoscopic interventions, including thermocoagulation with Bipolar Circum-Active Probe (BICAP). Biopsies of the ulcer margins were negative for dysplasia/malignancy.
During the third episode, combined therapy with epinephrine and 1% polidocanol (4 cc) was administered into the vessel. The following day, due to hematemesis, he repeated UGE that revealed extensive, friable, violet-colored ulceration of the gastric body and antrum, consistent with ischemic injury likely secondary to polidocanol injection. Patient was managed conservatively with proton pump inhibitors and antibiotics for one week.
After eight months of follow-up, he remains clinically stable, without episodes of rebleeding. A reassessment endoscopy showed only a scar retraction.
This case is presented based on the iconography of the adverse effect of polidocanol therapy (exuberant gastric ischemia), highlighting the risk of gastrointestinal necrosis. However, as this is a refractory ulcer with multiple episodes of rebleeding, polidocanol proved to be the most effective therapy. Literature describes similar risks with adrenaline and sclerosant agents. In this case, we suggest that direct arterial injury by the needle, followed by immediate luminal obliteration, led to ischemic damage.

References

Li WF, Gao RY, Xu JW, Yu XQ. Endoscopic treatment of bleeding gastric ulcer causing gastric wall necrosis: A case report. World J Gastrointest Surg 2024; 16(4): 1203-1207
Silva C, Monteiro C, Matos C, Martins A, Midões A. Extensive duodenal ischemia after endoscopic hemostatic therapy. Int J Case Rep Images 2022;13(2):202–204.
J. Molina-Infante, M. Fernandez-Bermejo, G. Vinagre-Rodríguez. Severe gastric ischemia after combined sclerotherapy for bleeding gastric ulcer. Endoscopy 2011; 43: E191.
G. Dorta, P. Michetti, P. Burckhardt, M. Gillet. Acute ischemia followed by hemorrhagic gastric necrosis after injection sclerotherapy for ulcer. Endoscopy 1996; 28.

Clinical Case Summary

A 30-year-old male was firstly evaluated at our gastroenterology outpatient clinic for chronic diarrhea, abdominal pain and weight loss (6kg in 4 months). His medical history included anal condylomatosis. Diagnostic workout for malabsorption syndrome was performed: celiac disease and other infective and noninfective causes of malabsorption were ruled out. Abdominal ultrasonography revealed invagination of the small intestine and mesenteric lymphadenopathy.
After HIV test positivity, a HAART (highly active antiretroviral therapy) with Dolutegravir/Lamivudine was set up. Soon after, the patient was admitted to Infectious Disease Unit for deep vein thrombosis and wasting syndrome.
Blood test showed mild anemia, severe hypoalbuminemia, electrolyte imbalance and slightly elevated inflammatory markers.
Esophagogastroduodenoscopy showed esophageal candidiasis, two precardial Herpetic erosions, hyperemic gastric mucosa, scalloping of duodenal folds with a mosaic pattern (fig.1).
Histological examination showed erosive chronic esophagitis with fungal hyphae and PAS+ spores; focally active chronic inflammation at antral and corpus level; duodenal villous atrophy (with intermediate severity) and crypt hyperplasia, with lymphoplasmacellular infiltrates in lamina propria and slightly increased intraepithelial CD3+ T lymphocytes. HSV, EBV and CMV tested positive at the immunostaining.
Colonoscopy with multiple biopsies showed substantial macroscopic normality, with mild chronic inflammation in every biopsy specimen.
Coproparasitological exam, coprocultures and serologic tests for enteropathogenes showed Candida albicans positivity.
During the hospitalisation, the patient received antiviral and antifungal therapy, HAART, albumin, fluid therapy, enoxaparin, energy-protein supplements.
At follow up, the patient continued HAART regularly, reaching full viral suppression. Weight gain was achieved, with no more episodes of diarrhea. Blood tests showed no more signs of malabsorption.

References

Figure 1. (endoscopic image) Duodenal mucosa (second portion) characterized by a mosaic pattern and flattened Kerckring folds with “scalloping”.

Clinical Case Summary

A 54-year-old man was referred to a Gastroenterology appointment due to weight loss and abnormal pancreatic findings on a CT scan, which revealed massive pancreatic enlargement. He had no relevant medical history. Endoscopic ultrasound demonstrated a globular pancreas with a hypoechoic but highly heterogeneous echotexture, multiple subcentimetric nodular formations and numerous millimetric hyperechoic foci, consistent with calcifications. Chromogranin A level was elevated at 143.2 ng/mL.
A 22G fine-needle aspiration of the pancreatic parenchyma was performed, but the result was inconclusive. Subsequently, PET/CT with 68Ga-peptides revealed a focal area of markedly increased uptake in the pancreatic tail (SUV max 47.8), highly suggestive of a neuroendocrine neoplasm, with increased radiotracer uptake throughout the pancreas. As a result, a percutaneous biopsy of the neoplasm and surrounding parenchyma (tail and body) was performed, confirming a well-differentiated (G1) pancreatic neuroendocrine tumor with amyloid stroma. Treatment was initiated with octreotide, later transitioned to lanreotide.
The patient underwent genetic evaluation, which revealed likely pathogenic variants c.1176+1_1176+7del p.? and c.361T>C p.(Cys121Arg) in the GCGR gene (heterozygous), confirming a diagnosis of Mahvash disease.
Two years later, during follow-up, abnormal liver function tests prompted abdominal magnetic resonance imaging, revealing liver nodules with characteristics of hypervascular metastases and signs of portal hypertension. An upper endoscopy was performed, revealing large esophageal varices with red spots, which were treated with two prophylactic elastic band ligations.
This case illustrates the development of portal hypertension arising from an extremely rare genetic disorder, with only about 15 confirmed cases of Mahvash disease reported to date. It is comprehensively documented through CT, PET imaging, histology, endoscopic ultrasound and upper endoscopy iconography.

References

- Yu, Run. “Plea to radiologists: Please consider Mahvash disease when encountering an enlarged pancreas.” World journal of radiology vol. 16,8 (2024): 371-374. doi:10.4329/wjr.v16.i8.371
- Robbins, Justin et al. “Liver Transplantation in a Woman with Mahvash Disease.” The New England journal of medicine vol. 389,21 (2023): 1972-1978. doi:10.1056/NEJMoa2303226

Clinical Case Summary

An 82-year-old man with Child B alcoholic cirrhosis, complicated by portal hypertension, underwent surveillance upper digestive endoscopy (UDE), revealing large esophageal varices and a 20 mm exophytic lesion, 40 cm from the dental arch, with an infiltrative and ulcerated appearance. Biopsies were inconclusive. Endoscopic ultrasound identified a heterogeneous, amorphous lesion with poorly defined borders and disruption of all wall layers, complicated by numerous large varices, preventing biopsy due to hemorrhagic risk. Computed tomography revealed parietal thickening in the distal esophagus and multiple varices, complicating lesion delineation. An oncology consultation recommended clinical surveillance, considering the patient's age, comorbidities, indeterminate nature of the esophageal lesion, and low suspicion for adenocarcinoma on ultrasound. One year later, surveillance UDE showed regression of the lesion.Histological samples were reviewed, revealing changes consistent with pyogenic granuloma. Pyogenic granuloma is a rapidly growing capillary hemangioma that may occur within the lumen of a pre-existing vessel (intravascular variant). The case is supported by appropriate iconography.

This case is presented with imaging, highlighting the challenge due to the macroscopic appearance suggestive of a neoplastic lesion and the pyogenic granuloma's growth within esophageal varices, limiting diagnostic and therapeutic management.

References

Clinical Case Summary

Introduction: Malakoplakia is a rare, chronic granulomatous inflammatory disease that results from impaired histiocyte clearance of bacteria in immune compromised individuals. We present a case of a post-lung transplant patient that was suspected to have diffuse colonic metastatic disease based on computed tomography (CT) that was later deemed to be diffuse malakoplakia related to systemic infection.
Case: A 62-year-old female with a history of lung transplant on Tacrolimus presented with abdominal distension and diarrhea. Vital signs were stable on arrival. Laboratory results including a complete blood count, liver and chemistry panels were noncontributory. Blood cultures repetitively grew Achromobacter xylosoxidans despite escalation of antibiotic therapy. Abdominal and pelvic CT demonstrated gastric distension, and a colonic filling defect at the hepatic flexure with extensive adenopathy evading the duodenal serosa. At this time there were concerns of metastatic colon cancer with concomitant systemic infection.
Interventional radiology performed a lymph node biopsy revealing malakoplakia and negative for malignancy. A colonoscopy was performed, showing diffuse nodularity with ulcerations with biopsies redemonstrating malakoplakia.
Discussion: Malakoplakia is a poorly understood chronic granulomatous inflammatory disease that results from bactericidal defect of histiocytes. This manifests in an accumulation of phagolysosomes most commonly in immune compromised individuals. Symptoms are non-specific ranging from asymptomatic to altered bowel habits, abdominal pain, rectal bleeding, and intestinal obstruction. Endoscopic appearance can range from flat lesions to multiple ulcerated polypoid nodules. Thus, as in this case, the diagnosis can often be delayed and result in unnecessary interventions until diagnosis is achieved. Once diagnosed antibiotic therapy is tailored to the culprit organism resulting an accumulation within histiocytes and killing the bacteria.

Clinical Case Summary

Background: Enteric duplication cysts are one of the rarest lesions detected in the pancreas. Pancreatic duplication cysts can be challenging to distinguish from neoplastic lesions, particularly in symptomatic patients. Radiologic imaging, such as Computed Topography (CT) and Magnetic Resonance Imaging (MRI), may not always provide a clear differentiation, leading to potential misdiagnosis.
Case presentation: We present the case of a Fifty-seven male patient with a history of long-standing epigastric pain, dyspepsia, and weight loss. Upper and lower endoscopy showed only mild gastritis. Abdominal CECT abdomen showed a well-circumscribed pancreatic lesion of about 20x25 mm with no vascular invasions. Endoscopic ultrasound showed a well-circumscribed pancreatic neck lesion about 20x22 mm, anechoic, negative color flow doppler, soft on elastography, free surrounded vessels with no posterior acoustic enhancement. EUS suggested a cystic lesion versus a vascular NET. EUS fine-needle aspiration (FNA) was done with aspiration of gelatinous material and onsite cytopathology suggested a benign cystic lesion. Further pathological interpretation confirms the diagnosis of a duplication cyst leading to appropriate management without avoidance of major invasive surgical intervention.
Conclusion: EUS and EUS-guided biopsy have a crucial role in differentiating benign pancreatic conditions from malignancies, particularly in patients presenting with nonspecific symptoms and ambiguous radiologic findings. EUS should be considered early in the diagnostic process to avoid misdiagnosis and unnecessary surgical procedures.

Disclosure

Nothing to disclose

Clinical Case Summary

Background: Endoscopic ultrasound (EUS)-guided cystogastrostomy with lumen-apposing metal stents (LAMS) is a widely accepted treatment for symptomatic pancreatic pseudocysts, particularly in cases of walled-off necrosis (WON). While the procedure is generally safe, delayed bleeding can occur. This report presents a novel approach to managing massive upper gastrointestinal bleeding following LAMS placement when interventional radiology (IR) embolization is not feasible.
Case presentation: A 51-year-old male with a history of pancreatitis and a large pancreatic pseudocyst underwent successful EUS-guided placement of an Axios stent. The patient was discharged on the second day of the procedure with no adverse events. Three days later, the patient developed significant melena, pallor, and a dramatic drop in hemoglobin levels, necessitating urgent blood transfusions. Diagnostic upper endoscopy revealed active pulsatile bleeding from the cyst wall behind the stent edge, which is inaccessible to conventional endoscopic methods. Two attempts of angiography by two different IR consultants failed to locate the bleeding source.
Given the critical situation and after resuscitation with IV blood transfusion, a multidisciplinary team proposed a novel technique: injection of Purastat, a hemostatic agent, into the cyst through the stent, followed by stent removal and additional application of glue over the cyst orifice. This approach successfully controlled the bleeding, stabilized the patient’s condition, and eliminated the need for surgery. Follow-up imaging revealed a small splenic artery aneurysm without active bleeding.
Conclusion: This case highlights the potential of Purastat as an effective tool for managing life-threatening gastrointestinal bleeding following LAMS placement. The successful use of this technique in sealing the cyst and stopping the bleeding suggests it could be a definitive management option in similar cases.

References

1. Shamah S, et al. Delayed bleeding after lumen-apposing metal stent placement for pancreatic fluid collections: Incidence, risk factors, and management. *Endoscopy International Open*. 2023;11(2):E158-E163.
2. Varadarajulu S, et al. Hemostasis in gastrointestinal endoscopy: Emerging techniques and devices. *Gastrointestinal Endoscopy Clinics of North America*. 2022;32(3):421-439.