Practical Teaching Cases

 

AGA Institute

The correct answer is B. The lead levels in serum and urine were tested (517 mcg/L, 0-400 mcg/L; 131.7 mcg/L, 0-70.38 mcg/L). A diagnosis of lead poisoning was made. Three days after chelation treatment, his symptoms disappeared and did not recur in the follow-up.

We carefully reviewed the patient’s history and found that he had been using jineijin, a traditional Chinese medicine (TCM) drug, which is made with dried endothelium corneum gigeriae galli (Figure E), at about 500 g/month and squama mantis (a TCM drug, at less than 5 g/month) as dietary supplements for 3 years.

AGA Institute

The level of lead in ground jineijin (Figure F, the drug the patients consumed is mainly processed by mixing ground jineijin and honey; Figure G, the deposit left after the elution of honey in Figure F is ground jineijin) and squama mantis was measured with inductively coupled plasma optical emission spectrometry, which proved to be 3,389 mg/kg, much higher than the maximal limit allowed for drinking water (less than 0.01 mg/kg). It is estimated that the patient’s daily lead intake from ground jineijin and squama mantis approximated 50 mg/day (acceptable limit being 100-300 mcg/day)¹ in the past 3 years.

AGA Institute

Jineijin has traditionally been used in China to alleviate nausea and vomiting.² With the rapid development of industry, heavy metal pollution of water and soil has been a widespread problem.³ Heavy metal enrichment may appear in poultry exposed to environmental population. Therefore, the lead content of jineijin obtained from poultry with high levels of lead exposure can easily exceed maximum acceptable limits. In this patient, long-term high-dosage consumption of jineijin may have been the source of lead exposure.
 

Acknowledgments

We thank Linshen Xie, MD, department of environmental health and occupational diseases, No. 4 West China Teaching Hospital, Sichuan University, for offering some clinical data. We thank the patient for giving permission to share his information.

References

1. National Research Council (US). Safe Drinking Water Committee. Drinking water and health. National Academy Press. Washington, D.C. 1977;1:309.

2. State Administration of Traditional Chinese Medicine. Advanced Textbook on Traditional Chinese Medicine and Pharmacology. New World Press, Beijing. 1995. (vol. 2).

3. Hui Hu, Q.J., Kavan, P. A study of heavy metal pollution in China: Current status, pollution-control policies and countermeasures. Sustainability. 2014;6:5820-38.
 

This article has an accompanying continuing medical education activity, also eligible for MOC credit, Learning objective: Upon completion of this examination, successful learners will be able to identify the features of lead poisoning.
 

 

AGA Institute

The correct answer is B. The lead levels in serum and urine were tested (517 mcg/L, 0-400 mcg/L; 131.7 mcg/L, 0-70.38 mcg/L). A diagnosis of lead poisoning was made. Three days after chelation treatment, his symptoms disappeared and did not recur in the follow-up.

We carefully reviewed the patient’s history and found that he had been using jineijin, a traditional Chinese medicine (TCM) drug, which is made with dried endothelium corneum gigeriae galli (Figure E), at about 500 g/month and squama mantis (a TCM drug, at less than 5 g/month) as dietary supplements for 3 years.

AGA Institute

The level of lead in ground jineijin (Figure F, the drug the patients consumed is mainly processed by mixing ground jineijin and honey; Figure G, the deposit left after the elution of honey in Figure F is ground jineijin) and squama mantis was measured with inductively coupled plasma optical emission spectrometry, which proved to be 3,389 mg/kg, much higher than the maximal limit allowed for drinking water (less than 0.01 mg/kg). It is estimated that the patient’s daily lead intake from ground jineijin and squama mantis approximated 50 mg/day (acceptable limit being 100-300 mcg/day)¹ in the past 3 years.

AGA Institute

Jineijin has traditionally been used in China to alleviate nausea and vomiting.² With the rapid development of industry, heavy metal pollution of water and soil has been a widespread problem.³ Heavy metal enrichment may appear in poultry exposed to environmental population. Therefore, the lead content of jineijin obtained from poultry with high levels of lead exposure can easily exceed maximum acceptable limits. In this patient, long-term high-dosage consumption of jineijin may have been the source of lead exposure.
 

Acknowledgments

We thank Linshen Xie, MD, department of environmental health and occupational diseases, No. 4 West China Teaching Hospital, Sichuan University, for offering some clinical data. We thank the patient for giving permission to share his information.

References

1. National Research Council (US). Safe Drinking Water Committee. Drinking water and health. National Academy Press. Washington, D.C. 1977;1:309.

2. State Administration of Traditional Chinese Medicine. Advanced Textbook on Traditional Chinese Medicine and Pharmacology. New World Press, Beijing. 1995. (vol. 2).

3. Hui Hu, Q.J., Kavan, P. A study of heavy metal pollution in China: Current status, pollution-control policies and countermeasures. Sustainability. 2014;6:5820-38.
 

This article has an accompanying continuing medical education activity, also eligible for MOC credit, Learning objective: Upon completion of this examination, successful learners will be able to identify the features of lead poisoning.
 

 

AGA Institute

The correct answer is B. The lead levels in serum and urine were tested (517 mcg/L, 0-400 mcg/L; 131.7 mcg/L, 0-70.38 mcg/L). A diagnosis of lead poisoning was made. Three days after chelation treatment, his symptoms disappeared and did not recur in the follow-up.

We carefully reviewed the patient’s history and found that he had been using jineijin, a traditional Chinese medicine (TCM) drug, which is made with dried endothelium corneum gigeriae galli (Figure E), at about 500 g/month and squama mantis (a TCM drug, at less than 5 g/month) as dietary supplements for 3 years.

AGA Institute

The level of lead in ground jineijin (Figure F, the drug the patients consumed is mainly processed by mixing ground jineijin and honey; Figure G, the deposit left after the elution of honey in Figure F is ground jineijin) and squama mantis was measured with inductively coupled plasma optical emission spectrometry, which proved to be 3,389 mg/kg, much higher than the maximal limit allowed for drinking water (less than 0.01 mg/kg). It is estimated that the patient’s daily lead intake from ground jineijin and squama mantis approximated 50 mg/day (acceptable limit being 100-300 mcg/day)¹ in the past 3 years.

AGA Institute

Jineijin has traditionally been used in China to alleviate nausea and vomiting.² With the rapid development of industry, heavy metal pollution of water and soil has been a widespread problem.³ Heavy metal enrichment may appear in poultry exposed to environmental population. Therefore, the lead content of jineijin obtained from poultry with high levels of lead exposure can easily exceed maximum acceptable limits. In this patient, long-term high-dosage consumption of jineijin may have been the source of lead exposure.
 

Acknowledgments

We thank Linshen Xie, MD, department of environmental health and occupational diseases, No. 4 West China Teaching Hospital, Sichuan University, for offering some clinical data. We thank the patient for giving permission to share his information.

References

1. National Research Council (US). Safe Drinking Water Committee. Drinking water and health. National Academy Press. Washington, D.C. 1977;1:309.

2. State Administration of Traditional Chinese Medicine. Advanced Textbook on Traditional Chinese Medicine and Pharmacology. New World Press, Beijing. 1995. (vol. 2).

3. Hui Hu, Q.J., Kavan, P. A study of heavy metal pollution in China: Current status, pollution-control policies and countermeasures. Sustainability. 2014;6:5820-38.
 

This article has an accompanying continuing medical education activity, also eligible for MOC credit, Learning objective: Upon completion of this examination, successful learners will be able to identify the features of lead poisoning.
 

 

The correct answer is C: colonic ischemia.

AGA Institute

The endoscopic findings are notable for colon single-stripe sign (CSSS), which is a highly specific feature of colonic ischemia (Figure A). The diagnosis of colon ischemia is further supported by the histologic features of cryptitis, focal fibrosis, and hemorrhage within the lamina propria (Figure B). In this case, the patient’s history of radiation exposure and hypotension were both likely predisposing factors for colonic hypoperfusion and subsequent colon ischemia. With conservative medical therapy, the patient experienced complete resolution of symptoms.

AGA Institute

Diverticular disease-associated colitis (answer A) is less likely given the lack of interdiverticular mucosal involvement and linear ulceration pattern, which also contrasts with the deep, “punched-out” appearance typically associated with ulceration of cytomegalovirus colitis (answer B). The endoscopic findings associated with chronic radiation colitis (answer D) characteristically include evidence of mucosal scarring, friability, and scattered angioectasias. The CSSS was initially described as a manifestation of colonic ischemia by Zuckerman et al. who hypothesized the linear nature of this lesion likely reflected segmental vascular compromise.1 Concordant with the presented case, of the 26 patients with CSSS included in the Zuckerman et al. study, all had a stripe measuring 5 cm in length while a minority (4 patients) had transverse colon involvement.1 Also in parallel with this case, others have reported successful nonoperative management of patients with CSSS in the setting of ischemia.1,2 Overall, the comparatively favorable outcome in patients with CSSS compared to those with circumferential colonic ischemia suggests this finding may reflect a more mild form of disease.1 n
 

References

1. Zuckerman G.R., et al. Am J Gastroenterol. 2003;98:2018-22.

2. Tanapanpanit O., Pongpirul K. BMJ Case Rep. 2015 Sept. 17;2015.

This article has an accompanying continuing medical education activity, also eligible for MOC credit (see gastrojournal.org for details). Learning Objective: Upon completion of this activity, successful learners will be able to recognize colon single-stripe sign as an endoscopic feature of colonic ischemia.
 

 

The correct answer is C: colonic ischemia.

AGA Institute

The endoscopic findings are notable for colon single-stripe sign (CSSS), which is a highly specific feature of colonic ischemia (Figure A). The diagnosis of colon ischemia is further supported by the histologic features of cryptitis, focal fibrosis, and hemorrhage within the lamina propria (Figure B). In this case, the patient’s history of radiation exposure and hypotension were both likely predisposing factors for colonic hypoperfusion and subsequent colon ischemia. With conservative medical therapy, the patient experienced complete resolution of symptoms.

AGA Institute

Diverticular disease-associated colitis (answer A) is less likely given the lack of interdiverticular mucosal involvement and linear ulceration pattern, which also contrasts with the deep, “punched-out” appearance typically associated with ulceration of cytomegalovirus colitis (answer B). The endoscopic findings associated with chronic radiation colitis (answer D) characteristically include evidence of mucosal scarring, friability, and scattered angioectasias. The CSSS was initially described as a manifestation of colonic ischemia by Zuckerman et al. who hypothesized the linear nature of this lesion likely reflected segmental vascular compromise.1 Concordant with the presented case, of the 26 patients with CSSS included in the Zuckerman et al. study, all had a stripe measuring 5 cm in length while a minority (4 patients) had transverse colon involvement.1 Also in parallel with this case, others have reported successful nonoperative management of patients with CSSS in the setting of ischemia.1,2 Overall, the comparatively favorable outcome in patients with CSSS compared to those with circumferential colonic ischemia suggests this finding may reflect a more mild form of disease.1 n
 

References

1. Zuckerman G.R., et al. Am J Gastroenterol. 2003;98:2018-22.

2. Tanapanpanit O., Pongpirul K. BMJ Case Rep. 2015 Sept. 17;2015.

This article has an accompanying continuing medical education activity, also eligible for MOC credit (see gastrojournal.org for details). Learning Objective: Upon completion of this activity, successful learners will be able to recognize colon single-stripe sign as an endoscopic feature of colonic ischemia.
 

 

The correct answer is C: colonic ischemia.

AGA Institute

The endoscopic findings are notable for colon single-stripe sign (CSSS), which is a highly specific feature of colonic ischemia (Figure A). The diagnosis of colon ischemia is further supported by the histologic features of cryptitis, focal fibrosis, and hemorrhage within the lamina propria (Figure B). In this case, the patient’s history of radiation exposure and hypotension were both likely predisposing factors for colonic hypoperfusion and subsequent colon ischemia. With conservative medical therapy, the patient experienced complete resolution of symptoms.

AGA Institute

Diverticular disease-associated colitis (answer A) is less likely given the lack of interdiverticular mucosal involvement and linear ulceration pattern, which also contrasts with the deep, “punched-out” appearance typically associated with ulceration of cytomegalovirus colitis (answer B). The endoscopic findings associated with chronic radiation colitis (answer D) characteristically include evidence of mucosal scarring, friability, and scattered angioectasias. The CSSS was initially described as a manifestation of colonic ischemia by Zuckerman et al. who hypothesized the linear nature of this lesion likely reflected segmental vascular compromise.1 Concordant with the presented case, of the 26 patients with CSSS included in the Zuckerman et al. study, all had a stripe measuring 5 cm in length while a minority (4 patients) had transverse colon involvement.1 Also in parallel with this case, others have reported successful nonoperative management of patients with CSSS in the setting of ischemia.1,2 Overall, the comparatively favorable outcome in patients with CSSS compared to those with circumferential colonic ischemia suggests this finding may reflect a more mild form of disease.1 n
 

References

1. Zuckerman G.R., et al. Am J Gastroenterol. 2003;98:2018-22.

2. Tanapanpanit O., Pongpirul K. BMJ Case Rep. 2015 Sept. 17;2015.

This article has an accompanying continuing medical education activity, also eligible for MOC credit (see gastrojournal.org for details). Learning Objective: Upon completion of this activity, successful learners will be able to recognize colon single-stripe sign as an endoscopic feature of colonic ischemia.
 

 

The correct answer is C: lymphocytic esophagitis.

AGA Institute

Histopathology showed well-differentiated squamous epithelium with dense intraepithelial lymphocytic infiltration of the peripapillary fields without neutrophilic or eosinophilic granulocytes. Focally there were areas with peripapillary intercellular edema/spongiosis (Figure B). There were CD3+/CD4+/CD8+ lymphocytes, without clear predominance of CD4+ or CD8+ lymphocytes (Figures C and D). Upon re-evaluation of the esophageal biopsies from the index endoscopy, neutrophilic granulocytes were reclassified as lymphocytes with shape alterations. Histopathology was diagnostic of LyE on both occasions.

AGA Institute

The histologic findings of LyE were described in 2006¹ as abundant intraepithelial lymphocytes in the peripapillary fields of esophageal squamous mucosa with only rare neutrophils and/or eosinophils present. There are reports on associations with reflux, hypothyroidism, Crohn’s disease, allergies, and asthma^1,2 but published reports are not unanimous.^2,3 The etiology of LyE remains unknown. There is a wide age distribution and no clear gender predominance. The course of LyE is considered to be chronic but benign.² Endoscopic findings suggestive of eosinophilic esophagitis, such as rings, are observed in 33.6% of LyE patients.³ Presenting symptoms are most often dysphagia or related to reflux. Treatment is symptomatic with PPI or balloon dilatation of strictures.

AGA Institute

The patient’s dysphagia had improved 3 months following balloon dilation. She declined further follow-up.
 

 

References

1. Rubio, C.A., Sjodahl, K., Lagergren, J. Lymphocytic esophagitis: A histologic subset of chronic esophagitis. Am J Clin Pathol. 2006;125:432-7.

2. Cohen, S., Saxena, A., Waljee, A.K., et al. Lymphocytic esophagitis: A diagnosis of increasing frequency. J Clin Gastroenterol. 2012;46:828-32.

3. Haque, S., Genta, R.M. Lymphocytic oesophagitis: Clinicopathological aspects of an emerging condition. Gut. 2012;61:1108-14.

This article has an accompanying continuing medical education activity, also eligible for MOC credit (see Gastroenterology website for details). Learning Objective: Upon completion of this teaching case and questions, the learners will be able to identify one typical clinical and endoscopic presentation of the entity lymphocytic esophagitis, distinguish its histological pattern from other esophageal disorders and recognize a variety of other clinical presentations of this condition.

 

The correct answer is C: lymphocytic esophagitis.

AGA Institute

Histopathology showed well-differentiated squamous epithelium with dense intraepithelial lymphocytic infiltration of the peripapillary fields without neutrophilic or eosinophilic granulocytes. Focally there were areas with peripapillary intercellular edema/spongiosis (Figure B). There were CD3+/CD4+/CD8+ lymphocytes, without clear predominance of CD4+ or CD8+ lymphocytes (Figures C and D). Upon re-evaluation of the esophageal biopsies from the index endoscopy, neutrophilic granulocytes were reclassified as lymphocytes with shape alterations. Histopathology was diagnostic of LyE on both occasions.

AGA Institute

The histologic findings of LyE were described in 2006¹ as abundant intraepithelial lymphocytes in the peripapillary fields of esophageal squamous mucosa with only rare neutrophils and/or eosinophils present. There are reports on associations with reflux, hypothyroidism, Crohn’s disease, allergies, and asthma^1,2 but published reports are not unanimous.^2,3 The etiology of LyE remains unknown. There is a wide age distribution and no clear gender predominance. The course of LyE is considered to be chronic but benign.² Endoscopic findings suggestive of eosinophilic esophagitis, such as rings, are observed in 33.6% of LyE patients.³ Presenting symptoms are most often dysphagia or related to reflux. Treatment is symptomatic with PPI or balloon dilatation of strictures.

AGA Institute

The patient’s dysphagia had improved 3 months following balloon dilation. She declined further follow-up.
 

 

References

1. Rubio, C.A., Sjodahl, K., Lagergren, J. Lymphocytic esophagitis: A histologic subset of chronic esophagitis. Am J Clin Pathol. 2006;125:432-7.

2. Cohen, S., Saxena, A., Waljee, A.K., et al. Lymphocytic esophagitis: A diagnosis of increasing frequency. J Clin Gastroenterol. 2012;46:828-32.

3. Haque, S., Genta, R.M. Lymphocytic oesophagitis: Clinicopathological aspects of an emerging condition. Gut. 2012;61:1108-14.

This article has an accompanying continuing medical education activity, also eligible for MOC credit (see Gastroenterology website for details). Learning Objective: Upon completion of this teaching case and questions, the learners will be able to identify one typical clinical and endoscopic presentation of the entity lymphocytic esophagitis, distinguish its histological pattern from other esophageal disorders and recognize a variety of other clinical presentations of this condition.

 

The correct answer is C: lymphocytic esophagitis.

AGA Institute

Histopathology showed well-differentiated squamous epithelium with dense intraepithelial lymphocytic infiltration of the peripapillary fields without neutrophilic or eosinophilic granulocytes. Focally there were areas with peripapillary intercellular edema/spongiosis (Figure B). There were CD3+/CD4+/CD8+ lymphocytes, without clear predominance of CD4+ or CD8+ lymphocytes (Figures C and D). Upon re-evaluation of the esophageal biopsies from the index endoscopy, neutrophilic granulocytes were reclassified as lymphocytes with shape alterations. Histopathology was diagnostic of LyE on both occasions.

AGA Institute

The histologic findings of LyE were described in 2006¹ as abundant intraepithelial lymphocytes in the peripapillary fields of esophageal squamous mucosa with only rare neutrophils and/or eosinophils present. There are reports on associations with reflux, hypothyroidism, Crohn’s disease, allergies, and asthma^1,2 but published reports are not unanimous.^2,3 The etiology of LyE remains unknown. There is a wide age distribution and no clear gender predominance. The course of LyE is considered to be chronic but benign.² Endoscopic findings suggestive of eosinophilic esophagitis, such as rings, are observed in 33.6% of LyE patients.³ Presenting symptoms are most often dysphagia or related to reflux. Treatment is symptomatic with PPI or balloon dilatation of strictures.

AGA Institute

The patient’s dysphagia had improved 3 months following balloon dilation. She declined further follow-up.
 

 

References

1. Rubio, C.A., Sjodahl, K., Lagergren, J. Lymphocytic esophagitis: A histologic subset of chronic esophagitis. Am J Clin Pathol. 2006;125:432-7.

2. Cohen, S., Saxena, A., Waljee, A.K., et al. Lymphocytic esophagitis: A diagnosis of increasing frequency. J Clin Gastroenterol. 2012;46:828-32.

3. Haque, S., Genta, R.M. Lymphocytic oesophagitis: Clinicopathological aspects of an emerging condition. Gut. 2012;61:1108-14.

This article has an accompanying continuing medical education activity, also eligible for MOC credit (see Gastroenterology website for details). Learning Objective: Upon completion of this teaching case and questions, the learners will be able to identify one typical clinical and endoscopic presentation of the entity lymphocytic esophagitis, distinguish its histological pattern from other esophageal disorders and recognize a variety of other clinical presentations of this condition.

The correct answer is B: endoscopic suture removal. As the prevalence of bariatric surgery increases to address the obesity epidemic, endoscopists are increasingly called upon to evaluate postbariatric patients.1 In one case series of patients undergoing EGD for upper GI symptoms post-RYGB, normal postsurgical anatomy was found in 31.6%, anastomotic stricture in 52.6%, marginal ulcer in 15.8%, unraveled suture material causing functional obstruction in 4% and gastro-gastric fistula in 2.6% of cases.2 Another series reported unraveled suture material thought to be contributing to upper GI symptoms in up to 10% of cases.3 Suture material is found by a mean of 34 weeks after RYGB, and presenting symptoms include abdominal pain in 65%, nausea 52%, dysphagia 22%, and melena in 13%. Unraveled suture material may be associated with marginal ulceration, or may cause obstruction as it presents a mechanical obstruction to foodstuff as it passes through the gastrojejunal anastomosis. A series of 29 therapeutic endoscopic suture removal cases reported resolution or improvement of symptoms in 83% of patients and no complications or anastomotic leaks.3

AGA Institute

Tools available for suture removal are diverse and should be selected based on the appearance of the unraveled suture material (Figure B). First, when possible the suture material should be untangled to allow for examination of the number and location of sutures involved, as well to evaluate the underlying mucosa for defects or ulceration. In the best case, more sutures may be removed if a grasping tool like a biopsy forcep is used to grip the suture where it emanates from the mucosa, then the scope is driven onto this area and the tool is firmly and quickly pulled back into the biopsy channel to break the suture. Other techniques include use of endoscopic scissors and loop cutters to trim and remove the suture material, though loop cutters may jam on braided or silk suture and are generally reserved for cutting monofilament.
While symptomatic management with antiemetics and analgesics (answer A) is important in managing this patient, it will not lead to definitive management of her underlying condition. The patient may require laparosopic surgical revision (answer C) if her symptoms persist after endoscopic suture removal, but it is premature to recommend this. An upper GI series (answer D) would be helpful in diagnosing a gastro-gastric fistula in this patient population, but the endoscopic evaluation suggests suture material leading to food bolus impaction and gut irritation is the cause of her symptoms. Finally, while the patient’s symptoms of intermittent obstruction raises concerns for gastrojejunal stenosis, the endoscopic exam showed a normal-caliber stoma. Thus, stomal dilation (answer E) is incorrect.

References

1. ASGE Standards of Practice Committee, Evans J.A., Muthusamy V.R., et al. The role of endoscopy in the bariatric surgery patient. Gastrointest Endosc. 2015;8:1063-72.
2. Lee J.K., Van Dam J., Morton J.M., et al. Endoscopy is accurate, safe, and effective in the assessment and management of complications following gastric bypass surgery. Am J Gastroenterol. 2009;104:575-82.
3. Yu S., Jastrow K., Clapp B., et al. Foreign material erosion after laparoscopic Roux-en-Y gastric bypass: findings and treatment. Surg Endosc. 2007;21:1216-20.

 

The correct answer is B: endoscopic suture removal. As the prevalence of bariatric surgery increases to address the obesity epidemic, endoscopists are increasingly called upon to evaluate postbariatric patients.1 In one case series of patients undergoing EGD for upper GI symptoms post-RYGB, normal postsurgical anatomy was found in 31.6%, anastomotic stricture in 52.6%, marginal ulcer in 15.8%, unraveled suture material causing functional obstruction in 4% and gastro-gastric fistula in 2.6% of cases.2 Another series reported unraveled suture material thought to be contributing to upper GI symptoms in up to 10% of cases.3 Suture material is found by a mean of 34 weeks after RYGB, and presenting symptoms include abdominal pain in 65%, nausea 52%, dysphagia 22%, and melena in 13%. Unraveled suture material may be associated with marginal ulceration, or may cause obstruction as it presents a mechanical obstruction to foodstuff as it passes through the gastrojejunal anastomosis. A series of 29 therapeutic endoscopic suture removal cases reported resolution or improvement of symptoms in 83% of patients and no complications or anastomotic leaks.3

AGA Institute

Tools available for suture removal are diverse and should be selected based on the appearance of the unraveled suture material (Figure B). First, when possible the suture material should be untangled to allow for examination of the number and location of sutures involved, as well to evaluate the underlying mucosa for defects or ulceration. In the best case, more sutures may be removed if a grasping tool like a biopsy forcep is used to grip the suture where it emanates from the mucosa, then the scope is driven onto this area and the tool is firmly and quickly pulled back into the biopsy channel to break the suture. Other techniques include use of endoscopic scissors and loop cutters to trim and remove the suture material, though loop cutters may jam on braided or silk suture and are generally reserved for cutting monofilament.
While symptomatic management with antiemetics and analgesics (answer A) is important in managing this patient, it will not lead to definitive management of her underlying condition. The patient may require laparosopic surgical revision (answer C) if her symptoms persist after endoscopic suture removal, but it is premature to recommend this. An upper GI series (answer D) would be helpful in diagnosing a gastro-gastric fistula in this patient population, but the endoscopic evaluation suggests suture material leading to food bolus impaction and gut irritation is the cause of her symptoms. Finally, while the patient’s symptoms of intermittent obstruction raises concerns for gastrojejunal stenosis, the endoscopic exam showed a normal-caliber stoma. Thus, stomal dilation (answer E) is incorrect.

References

1. ASGE Standards of Practice Committee, Evans J.A., Muthusamy V.R., et al. The role of endoscopy in the bariatric surgery patient. Gastrointest Endosc. 2015;8:1063-72.
2. Lee J.K., Van Dam J., Morton J.M., et al. Endoscopy is accurate, safe, and effective in the assessment and management of complications following gastric bypass surgery. Am J Gastroenterol. 2009;104:575-82.
3. Yu S., Jastrow K., Clapp B., et al. Foreign material erosion after laparoscopic Roux-en-Y gastric bypass: findings and treatment. Surg Endosc. 2007;21:1216-20.

 

The correct answer is B: endoscopic suture removal. As the prevalence of bariatric surgery increases to address the obesity epidemic, endoscopists are increasingly called upon to evaluate postbariatric patients.1 In one case series of patients undergoing EGD for upper GI symptoms post-RYGB, normal postsurgical anatomy was found in 31.6%, anastomotic stricture in 52.6%, marginal ulcer in 15.8%, unraveled suture material causing functional obstruction in 4% and gastro-gastric fistula in 2.6% of cases.2 Another series reported unraveled suture material thought to be contributing to upper GI symptoms in up to 10% of cases.3 Suture material is found by a mean of 34 weeks after RYGB, and presenting symptoms include abdominal pain in 65%, nausea 52%, dysphagia 22%, and melena in 13%. Unraveled suture material may be associated with marginal ulceration, or may cause obstruction as it presents a mechanical obstruction to foodstuff as it passes through the gastrojejunal anastomosis. A series of 29 therapeutic endoscopic suture removal cases reported resolution or improvement of symptoms in 83% of patients and no complications or anastomotic leaks.3

AGA Institute

Tools available for suture removal are diverse and should be selected based on the appearance of the unraveled suture material (Figure B). First, when possible the suture material should be untangled to allow for examination of the number and location of sutures involved, as well to evaluate the underlying mucosa for defects or ulceration. In the best case, more sutures may be removed if a grasping tool like a biopsy forcep is used to grip the suture where it emanates from the mucosa, then the scope is driven onto this area and the tool is firmly and quickly pulled back into the biopsy channel to break the suture. Other techniques include use of endoscopic scissors and loop cutters to trim and remove the suture material, though loop cutters may jam on braided or silk suture and are generally reserved for cutting monofilament.
While symptomatic management with antiemetics and analgesics (answer A) is important in managing this patient, it will not lead to definitive management of her underlying condition. The patient may require laparosopic surgical revision (answer C) if her symptoms persist after endoscopic suture removal, but it is premature to recommend this. An upper GI series (answer D) would be helpful in diagnosing a gastro-gastric fistula in this patient population, but the endoscopic evaluation suggests suture material leading to food bolus impaction and gut irritation is the cause of her symptoms. Finally, while the patient’s symptoms of intermittent obstruction raises concerns for gastrojejunal stenosis, the endoscopic exam showed a normal-caliber stoma. Thus, stomal dilation (answer E) is incorrect.

References

1. ASGE Standards of Practice Committee, Evans J.A., Muthusamy V.R., et al. The role of endoscopy in the bariatric surgery patient. Gastrointest Endosc. 2015;8:1063-72.
2. Lee J.K., Van Dam J., Morton J.M., et al. Endoscopy is accurate, safe, and effective in the assessment and management of complications following gastric bypass surgery. Am J Gastroenterol. 2009;104:575-82.
3. Yu S., Jastrow K., Clapp B., et al. Foreign material erosion after laparoscopic Roux-en-Y gastric bypass: findings and treatment. Surg Endosc. 2007;21:1216-20.