By Joel Joseph, MD and Klaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE

Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA

Case Presentation: 80-year-old patient with history of lung cancer on immune checkpoint inhibitor therapy presented with acute right lower abdominal pain, elevated inflammatory markers and mild lactic acidosis. The patient had rebound pain in the right lower quadrant and right flank. CT showed free air below the liver (Figure 1). During laparotomy a perforated duodenal ulcer was found. The omentum had wrapped itself to the perforation, which was sealed. There were inflammatory adhesions globally to anterior abdominal wall, pus in the infrahepatic space and right paracolic gutter and ecrotic omentum adjacent to abscess cavity.

Valentino´s syndrome is a rare condition caused by irritation of the peritoneum due to fluid from a perforated ulcer migrating into the paracolic sulcus (1, 2). This situation may mimic acute appendicitis or other differential diagnoses of right lower quadrant pain such as ureteral colic, diverticulitis, diverticulum rupture, ovarian torsion, ruptured ectopic pregnancy, perforated cholecystitis, pancreatitis, and pelvic inflammatory disease (1-3).

Rodolfo Pietro Filiberto Raffaello Gugliemi di Valentina d`Antonguolla), a famous Italian-American actor who starred in several well-known silent films of the 1920s (1, 2). Known in Hollywood as the “Latin Lover”, he died in 1926 at the age of 31 from septic complications (peritonitis and pleuritis) of an undiagnosed perforated peptic ulcer. This ulcer simulated appendicular abdominal pain and was treated surgically with an appendectomy, the final diagnosis being made at autopsy (1, 2).

References:

1. Kara Carmo F, Santorcuato Cubillos F, Maldonado Schoijet I. Valentino’s Syndrome: from History to Images. A Case-based Literature Review. Acta Gastroenterol Latinoam. 2023;53(2):188-192. https://doi.org/10.52787/agl.v53i2.313

2. Noussios G, Galanis N, Konstantinidis S, Mirelis C, Chatzis I, Katsourakis A. Valentino’s syndrome (with retroperitoneal ulcer perforation): A rare clinical-anatomical entity. Am J Case Rep [Internet]. 2020;21:e922647. http://dx.doi.org/10.12659/AJCR.922647

3. Wijegoonewardene SI, Stein J, Cooke D, Tien A. Valentino’s syndrome a perforated peptic ulcer mimicking acute appendicitis. BMJ Case Rep 2012;2012(jun28 1):bcr0320126015-bcr0320126015. http://dx.doi.org/10.1136/bcr.03.2012.6015

An 80-year-old on immune checkpoint therapy hits the ED with RLQ pain, rebound, and free air on CT—appendicitis, right? Laparotomy says no: perforated duodenal ulcer sealed by omentum. Classic Valentino’s syndrome, where fluid migration fools even seasoned clinicians.

This mimic persists as a pitfall, echoing Rudolph Valentino's fatal 1926 misdiagnosis. Today, with imaging at our fingertips, spotting atypical peritoneal sources saves lives and avoids unnecessary procedures.

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When perforations play hide-and-seek, be ready.

Tools of the Trade: The Retentia ® Clip

Klaus Mönkemüller, MD, PhD, FASGE, FJGES

Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA

Figure 1. Retentia Clip. Key technical information.

The Retentia Clip has some interesting and nice features: 

a) it is rotatable,

b) it can be deployed with scope in retroflexed position, 

c) it can open and close repeatedly. I opened and closed one 30 times,

d) its catheter has a 2.5 mm outer diameter, allowing for simultaneous suction of air and liquids through the working channel.

These are very convenient features, as they allows the endoscopist to be 100% sure of the desired placement location (vessel, base of polyp, wound closure, etc). Additionally, this clip is quite big, with arm extending up of 16 mm. This allows for grasping more tissue or tackling larger defects. Lastly, the clip’s stem is short (6 mm, yellow arrow), making it ideal for small lumens, such as esophagus or small bowel.

Disclaimer: I have no conflict of interest (COI). No commercial interest. 

Tools don't save patients—skilled hands do.

The Retentia clip offers 16mm arms and 360-degree rotation, but these features are useless without the clinical judgment to deploy them correctly. Knowing how to utilize a rotatable, reopenable clip allows for 100% certainty before you deploy.

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By Klaus Mönkemüller, MD, PhD, FASGE, FJGES, Troy Pleasant, MD, and Anand Dwivedi, MD

Virginia Tech Carilion School of Medicine, Virginia, USA

Transient or left-sided ischemic colitis is the most common type of ischemia of the gastrointestinal tract. Indeed, ischemic colitis is the second or third most common cause of lower GI bleeding. Herein we present two cases with classic features of transient ischemic colitis and focus on its endoscopic diagnosis.

Case Presentations:

Case 1: Elderly patient developed abdominal pain followed by bloody diarrhea. Colonoscopy showed patchy colitis of the left colon (Figure 1), the rectum was spared. Notice the patchy characteristic of this colitis. Panel A shows small ulcers with erythematous halo. In Panels C to E the classic Zuckerman sign can be appreciated. 

Figure 1. Endoscopic images from case 1.

A diagnosis of ischemic colitis was confirmed histologically. There were no significant risk factors for vascular occlusive disease or vasculitis. The patient improved with supportive measures, and she was discharged home two days later.

Case 2:

60-year-old female patient without significant past medical history presented with hematochezia that started after acute onset left sided abdominal pain. Only the bleeding continued, the pain disappeared after about 12-18 hours. CT of the abdomen revealed left sided colon stenosis and inflammation. Colonoscopy images are shown (Figure 2). 

Figure 2. Endoscopic images from case 2.

Colonic ischemia occurs due to changes in systemic circulation and/or alterations in local mesenteric vasculature. Left-sided ischemic colitis, also called transient ischemic colitis, is characterized by acute onset abdominal pain and bloody diarrhea or hematochezia. This condition can occur in any age group, but it is seen most in the elderly. Risk factors for transient ischemic colitis are atherosclerosis, heart failure, cardiac arrhythmias, shock, vasculopathies, abdominal aortic surgery, and hypercoagulability states. Indeed, the abrupt blood flow to the colon, which can occur after a marathon, exertion, or transient vessel occlusion from constriction (cocaine), thrombosis or low flow state can also result in transient ischemic colitis. Classic medications associated with ischemic colitis are estrogens, NSAIDs and alosetron (1).

The most frequently affected areas are the left colon and superior rectum, the lower rectum usually being spared because of its dual blood supply.

The main differential diagnoses of ischemic colitis are infectious colitis, diverticulitis, and inflammatory bowel disease. Therefore, stool cultures and histology are an important part of the work-up of patients presenting with abdominal pain and bloody stools. Regular stool cultures do not detect Klebsiella oxytoca or enterohaemorrhagic Escherichia coli, and this should be specifically stated in the microbiology request form. The diagnosis is established by endoscopy and histology (1).

The endoscopic spectrum of ischemic colitis is broad (Figure 3).

Figure 3. Endoscopic spectrum of ischemic colitis

Key elements though are sparing of the rectum and segmental distribution, mainly in the left colon (at the watershed area, arc of Riolan). These are called Sudeck’s and Griffith’s points or areas (Figure 4).

Figure 4. Watershed areas in transient left sided ischemic colitis (2).

In mild ischemic colitis there are usually segmentally distributed patchy erythema, edema and subepithelial hemorrhages. In moderate colitis, in addition to changes seen in mild disease, there are localized erosions and ulcers, which may be confluent. Often, a linear ulcer in the mesenteric border of the colon is seen. This is known as colon single strip sign (CSSS) or Zuckerman’s sign (1).

Figure 5. Colon single strip sign (CSSS) or Zuckerman’s sign.

In severe colitis there are deep ulcers, luminal narrowing and strictures and frank necrosis. 

Most cases of ischemic colitis are self-limited and do not require any specific medical or surgical therapy. However, in clinically unstable patients with signs of peritonitis colon resection should be considered.

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References:

1. Monkemuller K, Wilcox. Video GIE: https://www.videogie.org/article/S2212-0971(13)70152-3/fulltext

2. https://www.lecturio.com/concepts/mesenteric-ischemia/

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Diana Dougherty, MD, and Klaus Mönkemüller, MD, PhD, FASGE, FJGES
Department of Gastroenterology, Carilion Memorial Hospital, Virginia
Virginia Tech Carilion School of Medicine, Roanoke, USA

An 80-year-old man presented with melena. Esophagogastroduodenoscopy (EGD) revealed a large duodenal ulcer with a visible vessel, located anteriorly (Figure 1). Hemostasis was achieved with combination injection and compression electrocoagulation therapy using a injection gold probe.

Figure 1. Hemostasis with an injection gold probe catheter. A. Box of injection gold probe. The probe used was 7 Fr diameter. B. Notice the gold spiraled on the tip of the injection catheter. C. The gold probe can be placed laterally (tangentially) or perpendicular to the ulcer. D. The two important aspects are a) providing compression or pressure hemostasis and b) have enough gold touch the lesion to ensure cauterization of enough area (E). F. Successful hemostasis with disappearance of the visible vessel.

There is a large variety of tools to achieve endoscopic hemostasis. These are broadly classified into injection, thermal, mechanical and contact methods (1) (Figure 2).

Figure 2. Endoscopic Methods for Hemostasis. Thermal therapies are divided into argon plasma coagulation and probes that apply heat or electrosurgical current: monopolar, bipolar or multipolar electrocoagulation (MPEC) devices (1). With monopolar devices, the current passes through the patient and back to the unit via a return pad, whereas with bipolar or MPEC devices, the electric current is confined to the tissue between the electrodes within the instrument tip, obviating the need for a return pad (2).

An injection gold probe catheter is a bipolar hemostasis device that uses both injection and electricity to stop bleeding. We usually inject a mixture of saline epinephrine around the target area (e.g. visible vessel), followed by electrocauterization of tissue. The probe's tip heats tissue with electricity, which coagulates tissue and blood, thus stopping the bleeding. The probe's rounded tip provides uniform burn and coagulation. The probe's design reduces kinking, which helps it advance and tamponade tissue. The MPEC probe can be used tangentially to, or perpendicularly to, the bleeding source. Pressure is applied to compress and seal the walls of the bleeding vessel ("coaptive coagulation") (3). MPEC probes are available in 7F and 10F diameters with an irrigation port at the tip; the 10F probe requires the use of an endoscope with a 3.2 mm diameter instrument channel. Probe size, wattage, contact pressure and duration, and number of applications will vary depending on the lesion being treated (2).

Although we like to have this device in our toolbox for gastrointestinal bleeding, we don't use it very often, as there are other great options for hemostasis such as through-the-scope or over-the-scope clips. However, this case was ideal to use the injection gold probe as the ulcer was located anteriorly (i.e. on the working channel side of scope). If the ulcer is posteriorly, or on the right side of the scope, using injection or gold probe is quite difficult or impossible (3). In our experience we have not had any significant complications using the gold probe, but we have witnessed at least three cases of duodenal perforation in different hospitals. Therefore, we caution to be careful when performing pressure hemostasis, as the electrosurgical heat may damage deeper tissue levels (2, 4).

References:

1. Wasserman RD, Abel W, Monkemuller K, Yeaton P, Kesar V, Kesar V. Non-variceal Upper Gastrointestinal Bleeding and Its Endoscopic Management. Turk J Gastroenterol. 2024 May 20;35(8):599-608. doi: 10.5152/tjg.2024.23507. PMID: 39150279; PMCID: PMC11363156.

2. Parsi Me, et al. Devices for endoscopic hemostasis of nonvariceal GI bleeding (with videos). VideoGIE 2019;4:285-299.

3. Treating Upper Gastrointestinal Bleeding: An Update on Endoscopic Techniques - EndoCollab

4. Kumar VCS, Aloysius M, Aswath G. Adverse events associated with the gold probe and the injection gold probe devices used for endoscopic hemostasis: A MAUDE database analysis. World J Gastrointest Endosc. 2024 Jan 16;16(1):37-43. doi: 10.4253/wjge.v16.i1.37. PMID: 38313458; PMCID: PMC10835479.

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Through-the-scope clips have become the workhorse for many bleeding ulcers. But what about the tools we use less often, like the injection gold probe? This case is a perfect reminder of why a master endoscopist never forgets a tool in their kit.

This case shows a scenario where the gold probe offers excellent utility (effective "coaptive coagulation" on an anterior wall). Are you confident in your selection process for all hemostasis devices, even the ones you only pull out a few times a year?

📚 Get our new book: The EndoCollab Guide for GI Bleeding - Dive deep into strategies for acute GI bleeding, with practical frameworks for device selection and managing complications.

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Dieulafoy Lesion of the Duodenum

Klaus Mönkemüller, MD, PhD, FASGE, FJGES

Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA

An 72-year-old female with past medical history of chronic kidney disease stage IV, type 2 diabetes mellitus, atrial fibrillation presented with recurrent overt gastrointestinal bleeding (melena and hematemesis, hemoglobin 7.1 gr/dl). She had undergone two previous EGDs without significant findings. On EGD we found a bleeding Dieulafoy lesion of the duodenum (Figure 1). Hemostasis achieved with a hemoclip.

Figure 1. Dieulafoy lesion of the duodenum. A. Active bleeding. B. No evidence of ulceration or angiodysplasia. C. Successful hemostasis with a through-the-scope clip.

A Dieulafoy lesion is a rare, developmental vascular malformation in the gastrointestinal (GI) tract that can cause bleeding (1). This enlarged and erratic submucosal blood vessel may bleed in the absence of any visible abnormality, such as ulcers or erosions (1). However, on histology the vessel often results in an erosion of the mucosa, hence its classic name “exulceratio simplex” (2). Other names for Dieulafoy are cirsoid aneurysm and caliber-persistent submucosal vessel (1). A Dieulafoy lesion can occur anywhere in the GI tract, but most often in the stomach. This lesion is more common in males, the average age is 70 years. The most common symptoms are unexplained, recurrent, or massive GI bleeding. Dieulafoy lesion accounts for 6.5% of the causes of upper gastrointestinal hemorrhage (3). Therapy is mainly endoscopic, including epinephrine injection, electrocoagulation, or clip placement (1). In cases of severe bleeding, angiogram with selective embolization is an excellent option. Rarey, surgical resection may be necessary as a last resort.

Missed it twice. Found it on the third look.

This case highlights what every gastroenterologist knows: obscure GI bleeding is one of our toughest diagnostic challenges. Dieulafoy lesions are masters of disguise—accounting for 6.5% of upper GI hemorrhage yet often evading detection on initial endoscopy.

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References:

1. Malik TF, Anjum F. Dieulafoys Lesion Causing Gastrointestinal Bleeding.  StatPearls Publishing; 2025 Jan-.

2. Dieulafoy G. Exulceratio simplex: leçons 1–3. In: Dieulafoy G, editor. Clinique Médicale de l’Hotel Dieu de Paris. Paris, France: Masson et Cie; 1898. pp. 1–38.

3. Then EO, Bijjam R, Ofosu A, Rawla P, Culliford A, Gaduputi V. Rectal Dieulafoy's Lesion: A Rare Etiology of Lower Gastrointestinal Hemorrhage. Case Rep Gastroenterol. 2019 Jan-Apr;13(1):73-77

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Rami Musallam, MD, Gastroenterology Fellow, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

Andres Gutierrez, MD, Gastroenterology Fellow, Clinica de Gastroenteroogi “Prof. Carolina Olano”, Hospital de Clinicas, Universidad de La Republica, Uruguay and Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

Klaus Mönkemüller, MD, PhD, FASGE, FESGE, FJGES

Professor of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

85-year-old female patient with hypothyroidism, hyperlipidemia and iron deficiency anemia who was on oral iron supplementation (ferrous sulfate tablets, 325 mg once daily) presented with a 3-months history of abdominal pain and nausea. On EGD a round, 8-10 mm ulcer was seen in the distal body of the stomach (Figure 1). 

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The gastric ulcer biopsies demonstrate an ulcerating active gastritis. The gastric ulcer biopsies also contained embedded yellow-brown crystalline material in the lamina propria, which were positive by Prussian blue iron staining. No Helicobacter pylori organisms were seen on the biopsy specimens.

These findings confirmed with an iron pill gastropathy/gastritis. 

Oral iron tablets or pills can cause both focal and diffuse erosive gastritis. Iron has been noted to cause a focal erosive mucosal injury like that caused by a chemical burn (1). Iron deposits a brown-black crystalline hemosiderin into the mucosa (1). It is thought that iron erodes the mucosa through a direct corrosive effect that subsequently produces a local injury in a concentration-dependent manner (1). In some patients, particularly those with other comorbid conditions such as hemochromatosis, gastric antral vascular ectasia, and gastric adenocarcinoma, among others, the degree of iron deposition extends to the lamina propria and even the gastric glands (1). On endoscopy the spectrum of findings includes erosion, ulceration, focal hemorrhage or diffuse gastritis. In our experience the focal lesions are most commonly located in the greater curvature of the stomach body such as in this patient. Clinical presentations include epigastric pain, nausea, microcytic anemia, and occult gastrointestinal bleeding. This is a great irony, as iron is causing a big problem. . It is therefore important to consider this entity in patients with gastric ulcers who are on oral iron supplementation and in whom the search for more common causes of gastric ulceration including NSAID use and H pylori infection has been negative (2). Iron pill–induced mucosal injury can be reversed by discontinuing the offending agent or switching to a less toxic form such as a liquid iron preparation (2).

 In sum, iron pill gastritis may present as gastritis, multiple gastric erosions and ulcers.

The irony of iron: a treatment for anemia causing gastric ulcers is a crucial reminder that a diagnosis is not always straightforward. When common causes like H. pylori and NSAID use are ruled out, where do you turn next?

To master the full spectrum of GI bleeding, from common culprits to rare presentations like iron pill gastropathy, get your copy of our definitive book, 'The EndoCollab Guide for GI Bleeding'. https://amzn.to/40ugFRB

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References:

1. Hashash JG, Proksell S, Kuan SF, Behari J. Iron Pill-Induced Gastritis. ACG Case Rep J. 2013 Oct 8;1(1):13-5. doi: 10.14309/crj.2013.7. PMID: 26157809; PMCID: PMC4435261.

2. Parsi MA, Yerian LM. Iron ulcers. Clin Gastroenterol Hepatol. 2009 Oct;7(10):A22. doi: 10.1016/j.cgh.2009.01.005. Epub 2009 Jan 24. PMID: 19558995.

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Rami Musallam, MD, Gastroenterology Fellow,

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, Professor of Medicine

Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA 

 A 50-year-old patient with a history of cirrhosis due to ethanol use presented to the emergency room with hematemesis and melena for one day. The patient had clinical features consistent of chronic liver disease (spider angiomas, ascites, palmar erythema and jaundice). The hemoglobin was 8 gr/dl. An EGD was performed (Photo).

Figure 1. Large esophageal varices. A. Three columns of esophageal varices extending from the distal esophagus to the mid-esophagus. B. The stomach was full of coffee-ground like material, bile and blood clots. C. Classic nipple sign shown with yellow arrow. D. Nipple sign. E. The transparent banding cap allows for great visualization of the nipple sign (yellow arrow). F. No arrow on this photo to allow for “eye training” to detect nipple sign”. G. and H. Successful endoscopic band ligation of varix with high-risk stigmata (nipple sign).

There are various signs of impending or recent hemorrhage from esophageal varices. These include red stops, red whale sign, nipple-like sign and active bleeding (oozing or spurting) (1, 2). The “nipple-like projection” or “nipple sign” was described in 1996 (1). This lesion represents an opening varix covered by fibrin, indicating a recent bleed with spontaneous “hemostasis”. Any varix with nipple-like projection is at extremely high risk of (recurrent) bleeding, as this fibrin plug may fall off any time. Whenever this sign is encountered a quick decision to place endoscopic bands must be made. In this case we saw large esophageal varices (Panel A), then saw the lesion (Panels C and D). The stomach was full of old blood. As there was a clear culprit explaining the recent hemorrhage (fibrin nipple, panels C, D). Further cleaning of the stomach might have resulted in loss of the fibrin plug on the varix and catastrophic bleeding. Therefore, a quick decision was taken to place endoscopic band ligation on the high-risk lesion (panels E to H).

Recognizing a high-risk marker like the "nipple sign" can be the difference between routine banding and a catastrophic bleed. But what about the countless other challenging scenarios in GI bleeding?

For a comprehensive, practical approach to every situation, from varices to obscure bleeds, get your copy of our new book, 'The EndoCollab Guide for GI Bleeding'. https://amzn.to/40ugFRB

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References:

1. Caldwell SH, Bickston SJ, Yoshida C, Morse J, Yeaton P. Nipple-like projection from a varix: a high-risk marker? Gastrointest Endosc. 1996 Nov;44(5):634-5. doi: 10.1016/s0016-5107(96)70035-4. PMID: 8934186.

2. Wasserman RD, Abel W, Monkemuller K, Yeaton P, Kesar V, Kesar V. Non-variceal Upper Gastrointestinal Bleeding and Its Endoscopic Management. Turk J Gastroenterol. 2024 May 20;35(8):599-608. doi: 10.5152/tjg.2024.23507. PMID: 39150279.

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Endoscopic Resection of Giant Gastric Polyp to Treat Upper GI Bleeding

Anand Dwivedi, MD

Gastroenterology Fellow, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine

Klaus Mönkemüller, MD, PhD, FASGE, FJGES

Professor of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

An elderly patient presented with massive hematemesis and drop in hemoglobin from 13 to 9 gr/dl. After hemodynamic stabilization an EGD was performed. A large antral polypoid lesion with stigmata of hemorrhage was seen (A, B).

The polyp had a large and thick pedicle (C). The pedicle was injected with saline-epinephrine mix (1:10,000) (D). Endoscopic resection was performed using a snare (E). The resection defect was closed using two clips (F, G).  Panel H shows a 4 cm large pedunculated polyp. Histology showed a gastric hyperplastic polyp with no malignant features. The patient did not have any additional bleeding episodes.

This case shows that endoscopic resection may be an option to treat upper gastrointestinal bleeding. Two solutions were provided in one session a) removal of the source of bleeding (plus applying hemostatic clips to the resection site to prevent a post-polypectomy bleeding) and b) removal of a pre-malignant lesion. It is important to emphasize that hyperplastic gastric polyps larger than 10 mm carry an increased risk of transformation into cancer (1).

This case of upper GI bleeding from a giant gastric polyp highlights the critical, in-the-moment decisions endoscopists face. Deepen your expertise and connect with a global community of professionals in the EndoCollab paid membership. You'll gain access to an extensive library of videos, quick tips, and lectures covering a wide range of endoscopic procedures.

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And for a comprehensive, go-to resource on managing digestive tract hemorrhages, don't miss our new book, The EndoCollab Guide for GI Bleeding. It's the perfect companion for your clinical practice.

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References:

1. Fry LC, Lazenby AJ, Lee DH, Mönkemüller K. Signet-ring-cell adenocarcinoma arising from a hyperplastic polyp in the stomach. Gastrointest Endosc. 2005 Mar;61(3):493-5. doi: 10.1016/s0016-5107(04)02640-9. PMID: 15758936.

Images from EndoCollab. See endocollab.com for more information, including videos, quick tips and lectures on these and many other practical endoscopy tricks and techniques.

Klaus Mönkemüller, MD, PhD, FASGE, FJGES

Professor of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

The term “kissing ulcers” of the duodenum describes the presence of two different ulcers facing each other, usually one located anteriorly and the other posteriorly. It appears that the original description was in the surgical literature by Stabile et al in 1979 (Arch Surg). The photo shows a spectrum of kissing ulcers. Occasionally, these may be hard to see (Panel C, yellow arrows).

Multiple duodenal ulcers are a “red flag” and should always intrigue the endoscopist to think of: use of NSAIDs, Zollinger-Ellison syndrome, ischemia, vasculitis, Crohn’s disease, Bechet’s disease, lymphoma, and in immunocompromised or transplant patients think cytomegalovirus, GVHD.

This citation is from the paper by Stabile et al: “Among 70 cases of perforated duodenal ulcers treated by plication, eight were complicated by massive postoperative hemorrhage from a synchronous posterior "kissing" duodenal ulcer. Critical analysis revealed that only signs of gastrointestinal (GI) bleeding preoperatively had predictive value for postoperative hemorrhage. Twenty-four patients had one or more predictive signs, and eight actually bled postoperatively. There was a 50% mortality and 75% additional complication rate for the bleeders. In contrast, the non-bleeders had a mortality and a complication rate of only 18% and 35%, respectively.” (1)

References:

1. Stabile BE, Hardy HJ, Passaro E Jr. 'Kissing' duodenal ulcers. Arch Surg. 1979 Oct;114(10):1153-6. doi: 10.1001/archsurg.1979.

Images from EndoCollab. See endocollab.com for more information, including videos, quick tips, and lectures on these and many other practical endoscopy tricks and techniques.

Recognizing subtle but critical findings like kissing ulcers is a crucial skill. As the 1979 Stabile paper reminds us, these ulcers present a high risk of life-threatening hemorrhage—a situation every endoscopist must be prepared to manage.

• Master the Emergency: For a comprehensive, practical framework to confidently manage these and all other types of GI bleeding, our new book, The EndoCollab Guide for GI Bleeding, is the essential resource for your library. Available now in hardcover, paperback, and eBook.

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Jay Bapaye, MD, Gastroenterology Fellow, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

David Lebel, MD, Assistant Professor of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

Klaus Mönkemüller, MD, PhD, FASGE, FJGES

Professor of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

60-year-old male patient with multiple medical problems, including hypertension, coronary artery disease, and small bowel angiodysplasias, was admitted for worsening anemia despite oral iron supplementation. On EGD, a diffuse gastritis and a focally enlarged gastric fold of the greater curvature of the proximal stomach were noticed (Figure 1, panel A, B). Biopsies were obtained, revealing iron-pill gastritis (Panel C). 

Images via EndoCollab.com

Oral iron tablets or pills can cause both focal and diffuse erosive gastritis. Iron has been noted to cause a focal erosive mucosal injury like that caused by a chemical burn (1). Iron deposits a brown-black crystalline hemosiderin into the mucosa (1) (Panel C). It is thought that iron erodes the mucosa through a direct corrosive effect that subsequently produces a local injury in a concentration-dependent manner (1). In some patients, particularly those with other comorbid conditions such as hemochromatosis, gastric antral vascular ectasia, and gastric adenocarcinoma, among others, the degree of iron deposition extends to the lamina propria and even the gastric glands (1). On endoscopy, the spectrum of findings includes erosion, ulceration, focal hemorrhage, or diffuse gastritis. In our experience, the focal lesions are most commonly located in the greater curvature of the stomach body (Panels A, B, D). Clinical presentations include epigastric pain, microcytic anemia, and occult gastrointestinal bleeding. This is a great paradox, as iron is causing a problem. Gastritis results from iron deposits (brown-black crystalline hemosiderin) that damage the mucosa.

In sum, iron-pill gastritis or gastropathy is a frequently overlooked and missed diagnosis. Whenever you see a focally enlarged and erythematous gastric fold located in the greater curvature of the proximal stomach, often with tiny blood clots, or active blood oozing, think of iron pill gastritis. However, iron pill gastritis may occur in any part of the stomach and present as gastritis, multiple gastric erosions, and ulcers.

Next time you see a focally enlarged gastric fold with blood clots, you'll think "iron pill gastritis" immediately.

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References:

1. Hashash JG, Proksell S, Kuan SF, Behari J. Iron Pill-Induced Gastritis. ACG Case Rep J. 2013 Oct 8;1(1):13-5. doi: 10.14309/crj.2013.7. PMID: 26157809; PMCID: PMC4435261.

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Klaus Mönkemüller, MD, PhD, FASGE, FJGES

Professor of Medicine, Virginia Tech Carilion School of Medicine, Virginia, USA

A middle-aged patient was admitted with hematemesis and hemorrhagic shock. After hemodynamic stabilization, EGD was performed, showing active bleeding and a partially adherent blood clot on a huge duodenal ulcer. The blood and blood clot were removed with a water flush. However, if a clot is more tightly adherent, I prefer not to remove it.

Inspection revealed a large ulcer (B, yellow oval) and a visible large vessel (B, C, yellow arrows). A one-stop hemostatic procedure was accomplished with an 11/6t over-the-scope clip (D). The OTSC nicely compressed the ulcer bed and the massive visible vessel. 

Since the advent of OTSC, the concept of endoscopic hemostasis has completely changed, because now a single endoscopic therapy may be enough to achieve permanent hemostasis, instead of the previous approach of using "dual" endoscopic therapy. Originally, OTSC was introduced as rescue therapy for massive upper GI bleeding (1). Nowadays, OTSC is considered a first-line monotherapy for bleeding upper GI lesions (2, 3). Of course, dual or triple endoscopic therapy may be required for some cases, but it is not a "routine" approach anymore.

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References:

1. Skinner M, Gutierrez JP, Neumann H, Wilcox CM, Burski C, Mönkemüller K. Over-the-scope clip placement is effective rescue therapy for severe acute upper gastrointestinal bleeding. Endosc Int Open. 2014 Mar;2(1):E37-40. doi: 10.1055/s-0034-1365282. Epub 2014 Mar 7. PMID: 26134611; PMCID: PMC4423243.

2. Meier B, Wannhoff A, Denzer U, Stathopoulos P, Schumacher B, Albers D, Hoffmeister A, Feisthammel J, Walter B, Meining A, Wedi E, Zachäus M, Pickartz T, Küllmer A, Schmidt A, Caca K. Over-the-scope-clips versus standard treatment in high-risk patients with acute non-variceal upper gastrointestinal bleeding: a randomised controlled trial (STING-2). Gut. 2022 Jul;71(7):1251-1258. doi: 10.1136/gutjnl-2021-325300. Epub 2022 Mar 23. PMID: 35321938.

3. Faggen AE, Kamal F, Lee-Smith W, Khan MA, Sharma S, Acharya A, Ahmed Z, Farooq U, Bayudan A, McLean R, Avila P, Dai SC, Munroe CA, Kouanda A. Over-the-Scope Clips Versus Standard Endoscopic Treatment for First Line Therapy of Non-variceal Upper Gastrointestinal Bleeding: Systematic Review and Meta-Analysis. Dig Dis Sci. 2023 Jun;68(6):2518-2530. doi: 10.1007/s10620-023-07888-3. Epub 2023 Mar 21. Erratum in: Dig Dis Sci. 2024 Jan;69(1):311-313. doi: 10.1007/s10620-023-08159-x. PMID: 36943590.

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by Hiral Patel, MD, Robert Moylan, MD and Klaus Klaus Mönkemüller, MD, PhD, FASGE, FJGES

Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA

A 70-year-old woman with history of metastatic melanoma on treatment with ipilimumab presented with acute onset abdominal pain and bloody bowel movements. 

Figure 1. Immune checkpoint inhibitor induced colitis (“immune mediated colitis”). A. diffuse mucosal edema, loss of light reflex, erythema, granularity. B. Large amount of secretion and pus (“mucopus”). C. “Tubular” colon because of severe inflammation. D. Immune mediated colitis is associated with significant neutrophilic inflammation, hence pus. E. Descending colon stenosis due to massive edema and inflammation. F. IMC is often indistinguishable from inflammatory bowel diseases. G. Typical granularity of mucosa in IMC. NBI views of inflamed crypts (cryptitis, white spots).

Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that target cancer modulatory cells and immune processes such as cytotoxic T-lymphocyte antigen-4 (ipilimumab), and interaction between PD-1 and the ligands PD-L1 and programmed death ligand 2 (anti–PD-1 agents such as pembrolizumab, nivolumab) (1). Although ICIs have improved the treatment of several malignancies such as melanomas, their severe immune-related adverse events including hepatitis and colitis hamper their use in a significant proportion of patients (1, 2). Indeed, immune-mediated colitis (IMC) can occur in up to 25% (1, 2). On endoscopy, this iatrogenic colitis is very hard to differentiate from classical ulcerative colitis or Crohn’s disease. On histology there is more neutrophilic infiltration without chronic inflammation (1, 2). Therapy consists mainly on reducing or stopping the ICIs. In addition, corticosteroids are recommended for moderate and severe forms of colitis (1-3). Infliximab has also been shown to be beneficial, especially in those patients that do not respond to steroids (1-3. As ICIs are entering practice worldwide it is important to know about immune colitis. 

References: 

1. Som A, Mandaliya R, Alsaadi D, Farshidpour M, Charabaty A, Malhotra N, Mattar MC. Immune checkpoint inhibitor-induced colitis: A comprehensive review. World J Clin Cases. 2019 Feb 26;7(4):405-418. doi: 10.12998/wjcc.v7.i4.405. PMID: 30842952; PMCID: PMC6397821.

2. Hashash JG, Francis FF, Farraye FA. Diagnosis and Management of Immune Checkpoint Inhibitor Colitis. Gastroenterol Hepatol (N Y). 2021 Aug;17(8):358-366. PMID: 34602898; PMCID: PMC8475264.

3. Dougan M, Wang Y, Rubio-Tapia A, Lim JK. AGA Clinical Practice Update on Diagnosis and Management of Immune Checkpoint Inhibitor Colitis and Hepatitis: Expert Review. Gastroenterology. 2021 Mar;160(4):1384-1393. doi: 10.1053/j.gastro.2020.08.063. Epub 2020 Oct 17. PMID: 33080231.

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by Hiral Patel, MD, Robert Moylan, MD and Klaus Klaus Mönkemüller, MD, PhD, FASGE, FJGES

Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA

A 70-year-old man with history of hypertension and a stroke one year prior, since then using clopidrogel, presented with acute onset hematochezia and hemorrhagic shock. The patient was not taking any non-steroidals. A computed tomography angiography (CTA) showed active bleeding in the mid-jejunum (Figure 1 A). After hemodynamic stabilization an urgent single balloon enteroscopy was performed (Figure 1). Multiple small and large jejunal diverticula were found. There was a large diverticulum at about 100 cm distal to the duodenum with an ulcer on its inner wall (Figure 1C). The ulcer was treated with five clips. No further bleeding was observed.

Figure 1. Bleeding jejunal diverticulum. A. CTA showing active bleeding (extravasation of contrast, yellow circle) in the mid-jejunum. B. Large jejunal diverticulum (green arrow) with ulcer (yellow arrow). C. Large ulcer in the mouth of the diverticulum. D. Endoscopic hemostatic therapy using clips. E. Close up view of clipped ulcer.

Figure 2 shows several tips and tricks on the endoscopic approach of jejunal diverticula. First, always look for different shapes of folds or darker areas behind or on the front of folds (A). These are clues for the presence of diverticula, blood or ulcers. Second, the use of simethicone will remove bubbles that disturb the view (B). Third, place the scope in a position that the worki g channel allws for targeting and treating the culprit lesion in a directed and easy manner (E). Fourth, use lots of clips to ensure the best possible closure or approximation of the ulcer and/ or hemostasis

Figure 2. Bleeding jejunal diverticulum. A. Dark contents inside of a jejunal diverticulum. B. irregular mucosa of the ulcerated mouth (entrance) of the diverticulum. C. Jejunal diverticulum (green arrow) with ulcer (yellow arrow). D. Large ulcer. E. The working channel of the scope on the left allowed for nice direction and placement of the clips. F. Two initial clips. G. and H. When confronted with a deep small bowel clip aggressive hemostasis is essential, i.e. better two additional clips than one to few”

In summary, this case is interesting for several reasons. First, a CTA was the first test performed for his hematochezia. CTA is being performed more often as a first line test in patients with gastrointestinal bleeding, especially if a “lower” (i.e. colonic) source is suspected (1). Second, after clinical stabilization we decided to perform a deep enteroscopy, obviating EGD and colonoscopy. This was a logical approach, as the source of bleeding was quite evident on CTA. Importantly, performing a capsule endoscopy may have delayed the treatment of the bleeding diverticulum. And finally, the concept of emergent deep enteroscopy proved to be of value, as the culprit lesion was found. Emergent double balloon was first described in 2009 and its use has been confirmed by various authors (2, 3). Finally, this report also describes key tips for reaching a diagnosis and achieving hemostasis in bleeding jejunal diverticulosis.

References: 

1. Wu LM, Xu JR, Yin Y, Qu XH. Usefulness of CT angiography in diagnosing acute gastrointestinal bleeding: a meta-analysis. World J Gastroenterol. 2010 Aug 21;16(31):3957-63. doi: 10.3748/wjg.v16.i31.3957. PMID: 20712058; PMCID: PMC2923771.

2. Mönkemüller K, Neumann H, Meyer F, Kuhn R, Malfertheiner P, Fry LC. A retrospective analysis of emergency double-balloon enteroscopy for small-bowel bleeding. Endoscopy. 2009 Aug;41(8):715-7. doi: 10.1055/s-0029-1214974. Epub 2009 Aug 10. PMID: 19670141.

3. Pérez-Cuadrado Robles E, Bebia Conesa P, Esteban Delgado P, Zamora Nava LE, Martínez Andrés B, Rodrigo Agudo JL, López Higueras A, López Martin A, Latorre R, Soria F, Pérez-Cuadrado Martínez E. Emergency double-balloon enteroscopy combined with real-time viewing of capsule endoscopy: a feasible combined approach in acute overt-obscure gastrointestinal bleeding? Dig Endosc. 2015 Mar;27(3):338-44. doi: 10.1111/den.12384. Epub 2014 Nov 3. PMID: 25251991.

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Andres Gutierrez, MD; Klaus Mönkemüller, MD, PhD, FASGE, FJGES

Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA

A 75-year-old woman underwent colonoscopy for obscure gastrointestinal bleeding. Her procedure revealed a tortuous colon with numerous diverticula. Upon entering the ascending colon and cecum, multiple red mucosal lesions were found (Figure 1).

Figure 1. Endoscopic findings of "cat scratch colon." (A-C) Multiple bright red, linear marks on the mucosa of the ascending colon, resembling cat scratches. (D-F) A sharp, tight angulation in the distal ascending colon responsible for causing the barotrauma.

This was the characteristic appearance of “cat scratch colon.” Cat scratch colon is a colonoscopic finding characterized by mucosal tears or lacerations. These are usually a benign, superficial finding resulting from barotrauma during colonoscopy when CO₂ or air is used to insufflate the colon. Some underlying pathologies such as collagenous colitis or ischemic colitis may predispose to barotrauma and cat scratch colon. In this case, the etiology was pure barotrauma, resulting from CO₂ getting entrapped in the cecum and ascending colon due to a tight angulation in the distal ascending colon, which created a tight valve mechanism (Panels D, E, F).

In most cases, cat scratch colon is a harmless, incidental finding during colonoscopy and doesn't require specific treatment. However, it's important to recognize the finding and consider potential contributing factors.

Post-Polypectomy Bleeding: Tips to Prevent and Treat

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by Subhash Garikipati, MD and Klaus Klaus Mönkemüller, MD, PhD, FASGE, FJGES

Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA

A 35-year-old man presented with nausea and vomiting followed by hematemesis. During EGD prolapse gastropathy was diagnosed (Figure 1).

Figure 1. Prolapse gastropathy. Upper panels show the patchy area of prolapsed stomach fundus mucosa with erythema, edema and congestion (yellow circle, arrow shows scope). The proposed mechanism of formation of prolapse gastropathy is shown in the lower graphics (C, D) (graphics source: Byfield F et al. GIE 1998).

Prolapse or emesis gastropathy is an underrecognized cause of hematemesis (1, 2). This condition was initially described in the late 70s (1). Retching and vomiting results in prolapse of the lesser curvature of the stomach fundus into the esophagus (1-3). Temporary “prolapse with strangulation” results in submucosal edema, congestion and hemorrhages. Some experts also call this condition “mechanical gastritis of the cardia (3). We believe that prolapse gastropathy is a precursor of Mallory-Weiss tears and even Boerhaave’s syndrome. Therapy is aimed at relieving the underlying causes of nausea and vomiting. 

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Upper Gl Resection Techniques: Stomach

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References:

1. Retrograde gastric mucosal prolapse as a cause of haematemesis. Young GP, Thomas RJ, Wall AJ. Med J Aust. 1976;2:488–489. 

2. Hematemesis due to prolapse gastropathy: an emetogenic injury. Byfield F, Ligresti R, Green PHR, Finegold J, Garcia-Carrasquillo RJ. Gastrointest Endosc. 1998;45:527–529. 

3. Mechanical gastritis involving the cardia: the trauma of retching and vomiting. Chen YL. J Clin Gastroenterol. 1990;12:63–66.

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Jay Bapaye, MD and Klaus Mönkemüller, MD, PhD, FASGE, FJGES

Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA

A 78-year-old man presented with melena. Esophagogastroduodenoscopy (EGD) and colonoscopy were unremarkable. Capsule endoscopy showed active bleeding from the proximal jejunum, approximately 15 minutes after the capsule passed through the pylorus. The patient was sent to us for a single balloon enteroscopy. Since the bleeding was in the upper jejunum a decision was taken to perform push enteroscopy instead. A useful trick to improve performance of push enteroscopy is attaching a transparent distal cap to the pediatric colonoscope. (Figure 1).

Figure 1. Cap-Assisted Enteroscopy. The cap allows for improved traversing of small bowel kinks, keeps small bowel folds away and permits scope tip stabilization (A, B, C). This patient was in decubitus supine position. Using water during endoscopy allows for orientation, as water accumulates in the back (posterior) (B, C). This may be helpful for lesion localization. In addition, water allows for deeper enteroscopy, as the loops do not get massively distended with air or CO2. 

The angiodysplasia was localized about 30 cm past the ligament of Treitz. It was localized on a small bowel fold (Figure 2). 

Figure 2. Cap-Assisted Enteroscopy Argon Plasma Coagulation. A. Angiodysplasia on small bowel fold. B. Notice how the cap allowed for flattening the fold and clearly exposing the angiodysplasia. C. The cap allowed for scope tip stabilization and “centralization” of the lesion, allowing for direct and targeted argon plasma coagulation therapy. 

This case has several important take home messages. First, a single or double balloon enteroscopy may not always be necessary to reach lesions located in the upper jejunum. Indeed, push enteroscopy can be easily performed using a pediatric colonoscope, and this is available in most endoscopy units worldwide. Second, using a distal transparent cap allows for deeper small bowel intubation as well as improved visualization. Finally, the cap also allows for targeted application of endoscopic therapies, including injection, clipping and, as in this case, application of argon plasma coagulation (1-3).

References:

1. Wasserman RD, Abel W, Monkemuller K, Yeaton P, Kesar V, Kesar V. Non-variceal Upper Gastrointestinal Bleeding and Its Endoscopic Management. Turk J Gastroenterol. 2024 May 20;35(8):599-608. doi: 10.5152/tjg.2024.23507. PMID: 39150279; PMCID: PMC11363156.

2. Sumiyama, Kazuki et al. Endoscopic Caps. Techniques in Gastrointestinal Endoscopy, Volume 8, Issue 1, 28 - 32

3. Treating Upper Gastrointestinal Bleeding: An Update on Endoscopic Techniques - EndoCollab. 

Watch the Four Argon Plasma Coagulation (Apc) Techniques on EndoCollab

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Jay Bapaye, MD and Klaus Mönkemüller, MD, PhD, FASGE, FJGES

Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA

An 80-year-old female with past medical history of chronic kidney disease stage IV, type 2 diabetes mellitus, quadruple coronary artery bypass, aortic and mitral stenosis treated with bioprosthetic aortic and mitral valves, pacemaker and defibrillator presented with recurrent occult gastrointestinal bleeding and iron deficiency anemia (hemoglobin 6.1 gr/dl). The patient had undergone multiple upper endoscopies and colonoscopies without significant findings except for small colon adenomas and “gastritis” and duodenal “polyps”. On EGD we found a linear, nodular antral gastritis, suspicious for nodular gastric antral vascular ectasia (GAVE) (Figure 1). Biopsies were obtained, confirming the endoscopic suspicion of GAVE. The GAVE was treated with multiple band ligations.

Figure 1. Gastric antra vascular ectasia (GAVE) of nodular type. A. “Nodular gastritis” in reality GAVE. B. Notice the characteristic edematous, erythematous, nodular, pseudo-polypoid linear appearance of nodular GAVE. C. Endoscopic band ligation of nodular GAVE.

The classic teaching refers to Heyde’s syndrome as “the association of aortic stenosis and cecal angiodysplasias” (1-3). Whereas this is partially true, here you will learn that Heyde syndrome is a type of hemophilia (acquired von Willebrand disease) leading to GI bleeding from various types of gastrointestinal angiodysplasias (2-5). Most often the angiodysplasias are in the small bowel and colon, but they can be located anywhere. Moreover, GAVE is also a form of deranged angioneogenesis (angiodysplasia), which may occur in the setting of Heyde syndrome (6). Now we know that Heyde syndrome is primarily a hemophilia, namely a form of acquired von Willebrand syndrome (2-4). There is a malfunction of von Willebrand factor, leading to gastrointestinal hemorrhage. In addition, deranged von Willebrand activity leads to angioneogenesis and occurrence of angiodysplasias and GAVE in the GI tract (2-4, 6). Many patients with aortic stenosis stop bleeding and develop angiodysplasias after receiving a new aortic valve (7). However, there are reports showing that Heyde syndrome may persist or develop despite aortic valve replacement (8, 9).

This case has several important take home messages. First, careful inspection of the stomach may uncover conditions such as nodular GAVE (Figure 2). Second, GAVE should be added to the spectrum of angiodysplasias occurring in Heyde syndrome. And finally, endoscopic band ligation is an alternative treatment of nodular GAVE.

Figure 2. Classification of GAVE. GAVE is characterized by a “characteristic” endoscopic pattern, mainly represented by red spots either organized in stripes radially departing from pylorus (“watermelon stomach” or arranged in a diffused-way or “honeycomb stomach”). In addition, there is a nodular variety, where there are multiple enlarged and nodular folds in the antrum (2, 3). Despite this, GAVE is often misclassified or mis-diagnosed.

References:

1. Heyde, E.C. Gastrointestinal Bleeding in Aortic Stenosis. N. Engl. J. Med. 1958, 259, 196.

2. Warkentin, T.; Morgan, D.G.; Moore, J.C. Aortic stenosis and bleeding gastrointestinal angiodysplasia: Is acquired von Willebrand’s disease the link? Lancet 1992, 340, 35–37.

3. Batur P, Stewart WJ, Isaacson JH. Increased Prevalence of Aortic Stenosis in Patients With Arteriovenous Malformations of the Gastrointestinal Tract in Heyde Syndrome. Arch Intern Med. 2003;163(15):1821–1824. doi:10.1001/archinte.163.15.1821

4. Vincentelli A et al. Acquired von Willebrand in Aortic Stenosis. New Engl J Med. 2003

5. Okhota S, et el. Int. J. Mol. Sci. 2020, 21, 7804;

6. Dosi RV, Ambaliya AP, Patell RD, Sonune NN. Gastric antral vascular ectasia with aortic stenosis: Heydes syndrome. Indian J Med Sci. 2012 Mar-Apr;66(3-4):86-9. PMID: 23603627.

7. Tsuchiya S, Matsumoto Y, Doman T, Fujiya T, Sugisawa J, Suda A, Sato K, Ikeda S, Shindo T, Kikuchi Y, Hao K, Takahashi J, Hatta W, Koike T, Masamune A, Saiki Y, Horiuchi H, Shimokawa H. Disappearance of Angiodysplasia Following Transcatheter Aortic Valve Implantation in a Patient with Heyde's Syndrome: A Case Report and Review of the Literature. J Atheroscler Thromb. 2020 Mar 1;27(3):271-277. doi: 10.5551/jat.49239. Epub 2019 Aug 3. PMID: 31378751; PMCID: PMC7113142.

8. Akutagawa T, Shindo T, Yamanouchi K, Hayakawa M, Ureshino H, Tsuruoka N, Sakata Y, Shimoda R, Noguchi R, Furukawa K, Morita S, Iwakiri R, Kimura S, Matsumoto M, Fujimoto K. Persistent Gastrointestinal Angiodysplasia in Heyde's Syndrome after Aortic Valve Replacement. Intern Med. 2017 Sep 15;56(18):2431-2433. doi: 10.2169/internalmedicine.8603-16. Epub 2017 Aug 21. PMID: 28824071; PMCID: PMC5643169.

9. Oda, T., Kanamoto, R., Miyawaki, M. et al. Heyde-like syndrome occurring for the first time following aortic valve replacement with a bioprosthesis: a case report. Gen Thorac Cardiovasc Surg Cases 2, 52 (2023). https://doi.org/10.1186/s44215-023-00066-x

by Diana Dougherty, MD and Klaus Klaus Mönkemüller, MD, PhD, FASGE, FJGES

Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA

A 40-year-old pregnant woman presented with acute constipation and abdominal distention. A sigmoid volvulus was diagnosed (Figure 1). There was a transition point in the sigmoid colon with a “mesenteric swirl sign” (Figures 1B, 1C).

An emergency colonoscopy was performed to resolve the sigmoid volvulus and place a decompression tube. 

Colon decompression tubes are used for other conditions such as Ogilvie’s syndrome and megacolons. In this case we used a Marcon colon decompression set (see below, Figures 2 and 3). This tube-set is particularly practical and useful as it comes with a wire and the tube has a pigtail end. This pigtail configuration prevents damage to the mucosa or colon perforation once the tube has been placed and is left inside. In addition, the tube has many side holes that allow for passage of liquid stool and air (Fig. 1 and 3D).

Figure 2.

The key steps to deploy place a through-the-scope colon decompression tube are:

1. Know your equipment. As the tube is placed through the working channel of the scope, it is imperative to have a colonoscope with a channel large enough to accept the tube. Tubes with diameters of 8.5 Fr and 10 Fr require a 3.2 mm working channel. Larger diameter tubes cannot be placed through the endoscope!

2. First, feed the wire into the decompression tube (Figures 1E and 1F). This wire will “stiffen the tube and facilitate pushing it through the scope channel. 

3. Once a location has been chosen to deploy the decompression tube, the tube is pushed out under direct endoscopic visualization until it the pigtail “coils” (Figure 1F). One trick we used to allow for smooth pushing of the catheter is to inject some olive oil into the working channel of the scope. Injecting water is also an option. It is important to always keep the wire INSIDE the catheter and not push the wire outside the pigtail tip, as the wire can penetrate the mucosa or even cause perforation. In addition, often there is liquid or solid stool that limits visualization, and a ‘free” wire tip can be dangerous.

4. Figures 3G and 3H shows the exchange maneuver. The catheter is pushed out and the scope is removed (by the endoscopist or an assistant). The important aspect is to advance tube and pull scope out in a synchronized matter (exchange), as you do not want to pull the catheter out. A trick we used while pushing the catheter is to start gently and slowly removing the wire. Some experts like to remove the wire at the very end, but this can lead to catheter entanglement and sometimes the wire is “stuck” inside the decompression catheter. This can result in accidentally pulling the catheter out when trying to dislodge the wire.

5. Figure H shows the final tip. As mentioned above we like to flush the colon with lots of water, but in distended colons we also use lots of simethicone. This will decrease bubbles and, of course, gas.

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Anand Dwivedi, MD

Carilion Memorial Hospital

Virginia Tech Carilion School of Medicine

Roanoke

Klaus Mönkemüller, MD, PhD, FASGE, FJGES

Professor of Medicine, Virginia Tech Carilion School of Medicine, Virginia, USA

There is a myriad of instruments to remove swallowed objects greater than 6 cm in length (such as pens, pencils, and toothbrushes) including nets (e.g. Roth net), snares, forceps, tripod prongs, overtubes, and various distal scope attachment caps (soft short, stiff, capuchon). A large transparent distal attachment cap was developed to remove small metal pieces, specifically, clip fragments of the over-the-scope clip (Remove cap, Ovesco, Germany) (1) (Figure 1). 

We have also found this cap very useful to remove impacted meat from the esophagus. As this cap is three times larger than traditional “hard” caps (i.e. those used for banding) and has large capacity volume, we refer to it as the “mega cap” (Figures 1A-C). Herein we report on the novel use of the Remove cap for removing a swallowed pen from inside the stomach.

The cap is larger than any existing transparent cap and allows for suctioning most of the impacted meat inside. Its distal diameter is 16 mm with a cap length of 26 mm (effective “catch length of 22 mm) (Figures 1A-C). This results in an inner cap “catch-volume” of approximately 5 ml, which is almost double to that of traditional distal transparent caps. Another big advantage of this cap is its softness (elasticity, figures 1D-E), which allows for smooth introduction into the esophagus (Fig. 1F). Once inside the stomach the cap can be placed against the mucosa, which turns it into oval shape, thus increasing the ability to pull back a sharp end of the foreign body such has the pen tip, inside of the cap (Fig. 1G). Using a Raptor, rat-tooth or alligator forceps is mandatory, was it is important to tightly grab the pen. A snare may be an option, but too often the snares slid off pens and pensils, especially if the object has been inside the stomach for several outs and is now covered by mucus and secretions. Specific tricks to remove a pen from the stomach are (Figure 2): 

a) Slowly place the distal part of the cap onto the pen, 

b) Move with the cap towards the proximal end of the pen. In this case it was the sharp, painting part (Fig. 1A), 

c) Do not grasp the pen on its very tip, but focus on the groove on “neck” (Fig. 1B), 

d) Close the forceps slowly, as closing to fast may result in it sliding over the foreign body (Fig. 1C), 

e) Once the forceps is tightly closed against the pen tip go ahead and pull the pen into the cap (Fig. 1D), 

f) Because this cap is soft it allows for “deformation” while the pen tip is being pulled inside. With hard caps it would be very hard or impossible to get a pen tip into it (Fig. 1E-F), 

g) Once the pen tip (or most of it) is inside the cap, commence pulling the scope out. It is very important that the forceps shaft is held with the left hand in place. Hard caps would never allow a tip to get inside, 

h) Keep insufflating air (or CO2) to distend the esophageal lumen and gently torque the scope to right and left, 

i) Gently pull the scope out, while continuously torquing right and left. The torquing maneuver decreases the chances of the pen tip to get caught or hung up on the esophageal mucosa or any of the esophageal anatomic (physiologic) stenotic areas. 

For the final extraction maneuver it is important to have the patient’s neck hyperextended and that the assistant is ready to catch the pen inside of the mouth. Fig. 1G shows the extracted pen. The entire extraction procedure lasted 4 minutes. In sum, this novel cap is a new addition to the armamentarium for remove long, sharp and pointed foreign bodies from inside the GI tract.

References:

1. Bauder M, Meier B, Caca K, Schmidt A. Endoscopic removal of over-the-scope clips: Clinical experience with a bipolar cutting device. United European Gastroenterol J. 2017 Jun;5(4):479-484. doi: 10.1177/2050640616671846. Epub 2016 Oct 6. PMID: 28588877; PMCID: PMC5446147.

Images from EndoCollab. See endocollab.com for more information, including videos, quick tips and lectures on these and many other practical endoscopy tricks and techniques.

Related Course Videos on EndoCollab

1. Overtubes in GI Endoscopy

2. Endoscopic Removal of Coins From the Esophagus

3. Using Overtube to Remove Distally Migrated Esophageal Stent

4. Using the Mega Cap (RemOVE) to Remove Meat Impaction and Foreign Bodies

Jacob C Davis, DO

Internal Medicine Resident, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine 

Klaus Mönkemüller, MD, PhD, FASGE, FESGE, FJGES

Professor of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

A 61-year-old male with a past medical history significant for DVT/PE on Eliquis and HTN presented to the emergency room after a questionable syncopal episode and a ground level fall. He was found to have a right orbital fracture as well as T8 and L2 vertebral fractures. GI was consulted for abdominal distention, LUQ abdominal pain. A CT abdomen/pelvis showed a distended gallbladder with wall thickening suspicious for acute cholecystitis, L2 acute compression fracture, bilobed abdominal aortic aneurysm, and distention of right and transverse colon. An abdominal ultrasound was done at that time as well showing an abnormal gallbladder with distention and wall thickening, which was suspicious for acalculous cholecystitis. HIDA scan was normal at that time. A KUB was obtained a few days later showing non-dilated small bowel loops, moderate air distention of transverse and descending colon, marked air distention of cecum suspicious for cecal ileus (A, B).

Cecal volvulus occurs because of the cecum twisting around its mesentery, often leading to a bowel obstruction (1). If unrecognized and untreated cecal volvulus can lead to bowel perforation and fecal peritonitis (1). Cecal volvulus accounts for roughly 10% of volvulus cases and typically occurs in younger patients compared to sigmoid volvulus (1). Patients with a developmental failure of peritoneal fixation of the proximal colon and restriction of bowel movement at fixed point from prior adhesions, mass, or scarring are risk factors for development of cecal volvulus (1). On KUB you will typically see marked distention of a loop of large bowel extending from the RLQ to the epigastric area or LUQ which can resemble a coffee bean, as seen above in figures A/B. A contrast enema or abdominal CT scan can be done for further characterization. Treatment options depend on the presence of colonic ischemia and tissue viability (1). In cases where the cecum is not viable a right hemicolectomy is indicated (1). In cases where there is no tissue ischemia treatment involves laparoscopic reduction or colonoscope reduction for patients that cannot tolerate surgery (1). However reduction alone is associated with a high risk of recurrence so cecopexy which involves attaching the cecum to the bowel wall is recommended (1). 

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References: 

1. Gaillard F, Walizai T, Anan R, et al. Cecal volvulus. Reference article, Radiopaedia.org (Accessed on 05 Nov 2024) https://doi.org/10.53347/rID-1041