Moderator: Mitchell L. Schubert, MD, FACG Presenters: Sanjay Bangarulingam, MD and Pritesh Mutha, MD, MPH
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1 Virginia Commonwealth University Fellow Presentations Moderator: Mitchell L. Schubert, MD, FACG Presenters: Sanjay Bangarulingam, MD and Pit Pritesh hm Mutha, MD, MPH Benign Esophageal Stricture Sanjay Bangarulingam, MD Mitchell Schubert, MD Virginia Commonwealth University McGuire VAMC Richmond, Virginia 1
2 Case 54 year old schizophrenic male with longstanding GERD c/o: Progressive dysphagia for solids and liquids, beginning Jan 2014 Inability to swallow secretions 30 lbs weight loss over 3 months History EGD (2010): LA Grade D esophagitis Esophagram (01/2014): reflux; stricture EGD (02/2014): esophagitis; stricture PEG (02/2014): nausea, vomiting, dysphagia, weight loss 2
3 Past Medical History Paranoid schizophrenia Esophagitis (LA Grade D) n Social History Resides in assisted living i facility. n Smokes 1 ppd X 10 years. n Alcohol abuse Medications Pantoprazole 40 mg bid Calcium 600 mg qd Clonazepam 1 mg Olanzapine 15 mg 3
4 Vitals stable Cachectic Physical Exam Otherwise normal exam with PEG tube in place EGD (April 2014) Unable to pass guidewire for dilation 4
5 Fluoroscopy Esophageal Scope PEG Scope Retrograde Wire 5
6 TTS Balloon Unable to open stricture Stent Deployment 6
7 Fully Deployed Stent Alimax Fully Covered Metal Stent Stent Removed After 4 Weeks 7
8 Stent Upsized to 18mm Stents for Benign Esophageal Strictures Ideal Stent Characteristics Easily placed Easily retrieved, repositioned, & removed Small-caliber delivery device Minimal shortening on deployment Low migration rates 8
9 Esophageal Stents for Benign Stricture Self Expandable Metal Stents(SEMS): Fully Covered Self Expandable Plastic Stents (SEPS): Biodegradable Stents Self Expanding Plastic Stents SEPS Only FDA approved stent for benign ES Relatively low cost Minimal tissue injury Easily repositionable and retrievable Clinical success: <50% High stent migration rates 9
10 Self Expanding Metal Stents SEMS Increasingly gy used for refractory benign esophageal strictures Not FDA approved No long-term prospective controlled trials Small studies suggest benefit SEP vs FC-SEM vs BDS Prospective 12-week stent treatment trial 32wk f/u patency, migration, relief of dysphagia n = 10 each Canena JM et al BMC Gastroenterol Jun 12;12:70 10
11 FC-SEP vs FC-SEM vs BDS Prospective 12-week study patency, migration, relief of dysphagia n = 10 each Canena JM et al BMC Gastroenterol Jun 12;12:70 FC-SEP vs FC-SEM vs BDS Prospective 12-week study patency, migration, relief of dysphagia n = 10 each FC-SEP FC-SEM BIODEGRAD MIGRATION 60% 30% 20% DYSPHAGIA RESOLVED 10% 40% 30% 11
12 Stents for Benign Esophageal Strictures Indications Refractory/recurrent or Complex stricture Weight Loss Aspiration Pain Decreased quality of life Stents for Benign Esophageal Strictures Complications: Immediate Aspiration Delivery system malfunction Malposition Dislodgement Perforation 12
13 Stents for Benign Esophageal Strictures Complications: Early (<1 wk) Chest pain Nausea Bleeding Stents for Benign Esophageal Strictures Complications: Late Recurrent dysphagia due to food impaction or migration Perforation (T-E fistula) Bleeding GERD (aspiration) 13
14 Conclusion Esophageal stenting is an effective option in refractory benign esophageal strictures Efficacy is modest, at the present time, due to migration and complications; expertise required Although no firm data, FC-SEMS are currently preferred over FC-SEPS due to ease of deployment, decreased migration, and efficacy Virginia Gastroenterology Symposium 2014 Clinical Vignette Pritesh Mutha, MD, MPH Chief Fellow Gastroenterology, Hepatology & Nutrition Virginia Commonwealth University McGuire VAMC 14
15 History 54 y/o AAM w/ PMH of chronic HCV GT1a presents to the ED with one day h/o chest pain, nausea, and vomiting 6 days post-liver biopsy No melena or hematochezia Cardiac enzymes negative. Hgb at baseline (14), lipase nl Discharged home after symptomatic treatment History Patient returns the very next day c/o sharp epigastric pain and is admitted to the hospital No other symptoms 15
16 Past Medical History Perforated duodenal ulcer s/p ex lap: 1995 Cholecystectomy: 2002 Polysubstance abuse Chronic HCV GT1a, treatment-naïve naïve History/Exam Medications Omeprazole Methadone Senna Gabapentin Aspirin Cyclobenzaprine Family history: No GI/liver disease in 1st degree family members Social History: Remote IVDU Tobacco 1ppd Alcohol quit 20 years ago Physical exam: VSS, Icteric No peritoneal/pleuritic signs 16
17 Labs CBC: Hgb 13.9; wbc 4.1; plt 234 LYTES: 135/4.1/96/27; 13/1.2; 138 HEART: Cpk/troponins normal PANCREAS: lipase/amylase normal LIVER: inr 1.0; alb 4.3; ast 151 (baseline 42); alt 208 (baseline 40); ap 221 (baseline 84); TB 4.2 (baseline 0.4) URINE: + methadone Differential diagnosis? 17
18 Differential diagnosis? Exacerbation of viral hepatitis Liver infection (related to biopsy) Bile peritonitis Subcapsular hematoma Intrahepatic bleed Choledocholithiasis (post cholecystectomy) Differential diagnosis? Exacerbation of viral hepatitis Liver infection (related to biopsy) Bile peritonitis Subcapsular hematoma Intrahepatic bleed Choledocholithiasis (post cholecystectomy) 18
19 CT abdomen with contrast New 12 mm lesion in right hepatic lobe Normal pancreas & bile ducts CT abdomen with contrast New 12 mm lesion in right hepatic lobe Normal pancreas & bile ducts Not explain symptoms/labs 19
20 Hospital course The very next day, the epigastric pain worsened and now radiated to the back. In addition, two dark-red red jelly-like like bowel movements. Hgb decreased from Transaminases remained elevated (ast 151, alt 208, Ap 221) Bili increased (direct 4.9) Lipase now elevated to 4500!!! Suspected Diagnosis Hemorrhagic pancreatitis from CBD stone 20
21 Suspected Diagnosis Hemorrhagic pancreatitis from CBD stone Unrelated to liver biopsy Unlikely to cause bloody bowel movements Suspected Diagnosis Hemorrhagic pancreatitis from CBD stone Hemobilia: GI bleeding; clot in CBD causing obstruction and pancreatitis Related to liver biopsy 21
22 Suspected Diagnosis Hemorrhagic pancreatitis from CBD stone Hemobilia: GI bleeding; clot in CBD causing obstruction and pancreatitis Related to liver biopsy What diagnostic test to perform? Day 3: EGD EGD : blood at ampulla 22
23 Day 3: EGD EGD : blood at ampulla What next???? ERCP Blood draining from major papilla No blood cast/ filling defects on balloon sweep of the CBD 23
24 GOOD NEWS: Hospital Course Lipase returned to normal Pain improved BAD NEWS Bleeding continued Hypotensive Hgb drops to 7.6 GOOD NEWS: Hospital Course Lipase returned to normal Pain improved BAD NEWS Bleeding continued Hypotensive Hgb drops to 7.6 WHAT NEXT??? Transfer to MICU Angiography 24
25 CT Angiogram Pseudoaneurysm right hepatic lobe Mesenteric Arteriogram with Coil Embolization of Pseudoaneursym Right hepatic artery (4 th order branch) cannulated and embolized with microcoils 25
26 Post Embolization Bleeding ceased Discharged 2 days later Hgb 11 ALT 93/AST 72/TB 1.0 Lipase 206 Hemobilia Bleeding into the biliary tree due to abnormal communication between a vessel of the splanchnic circulation and the biliary system May occur days to months after injury to liver Etiology: Trauma; Iatrogenic Curr Gastroenterol Rep 12:121-9,
27 Diagnosis Quincke s triad (22%-37.9%) Upper abdominal pain (52%) Upper gastrointestinal bleed (73%) Jaundice (30%) Br J Surg Jun;88(6): Diagnosis EGD or side-viewing duodenoscopy ERCP MRCP CT hepatic angiography Conventional angiography Am J Gastroenterol 1994, 89:
28 Management Hemodynamic resuscitation Control hemorrhage/treat underlying etiology Angiography Surgery Maintain biliary patency ERCP Hemobilia-induced induced pancreatitis Eleven case reports of hemobilia-induced induced acute pancreatitis following percutaneous liver biopsy Management: Observation ERCP with sphincterotomy (clot in CBD) Surgical removal of blood clot 28
29 CONCLUSION Hemobilia Post Liver Biopsy Should be suspected when patient presents with the classic triad: GI bleeding Biliary/abdominal pain Jaundice Most commonly occurs in a delayed fashion (mean: 5 days) due to gradual erosion of a biopsy- induced hematoma or pseudoaneurysm sm into the bile duct. Diagnosis: EGD; ERCP; MRCP; CT; Angiography Treatment: Conservative Embolization Surgery 29
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