Endoscopic Insufflation–Induced Gastric Barotrauma during Percutaneous Endoscopic Gastrostomy: A Report of Three Patients and Review of Literature

Background We report three patients with endoscopic insufflation–induced gastric barotrauma (EIGB) during upper gastrointestinal endoscopy (UGIE) for percutaneous endoscopic gastrostomy (PEG). A definition and classification of EIGB is proposed. Materials and Methods Records of patients undergoing UGIE over 7 years (April 2013–March 2020) were reviewed. Patients who developed new onset of bleeding or petechial spots in proximal stomach, in an area previously documented to be normal during the same endoscopic procedure, were studied. Results New onset of bleeding or petechial spots in proximal stomach occurred in 3/286 (0.1%) patients undergoing PEG and in none of the 19,323 other UGIE procedures during the study period. All patients were men with median age 76 years (range 68–80 years), with no coagulopathy. Aspirin and apixaban were discontinued 1 week and 3 days prior to the procedure. Fresh blood was noted in the stomach at a median of 275 seconds (range 130–340) seconds after commencement of endoscopy. At retroflexion, multiple linear mucosal breaks of up to 3 cm, with oozing of blood, were noted in the proximal stomach along the lesser curvature, close to the gastroesophageal junction in two patients. In the third patient, multiple petechial spots were noticed in the fundus. The plan for PEG was abandoned and the stomach deflated by endoscopic suction. There was no subsequent hematemesis, melena, or drop in hemoglobin. One week later, repeat UGIE in the first two patients revealed multiple healing linear ulcers of 1 to 3 cm in the lesser curvature and PEG was performed. Conclusion Overinsufflation over a short duration during UGIE may lead to EIGB. Early detection is key and in the absence gastric perforation, patients can be managed conservatively.

Reconstructive stage of surgery after cardiectomy

There is no consensus regarding the operation of choice for pathological changes in the proximal stomach, distal esophagus and the area of the cardio-esophageal junction to the present day. In addition to malignancy and peptic ulcer disease, a refractory course of gastroesophageal reflux disease (GERD) and the absence of any effect from primary antireflux surgery may be an indication for performing cardiectomy with reconstruction. To make a choice of the surgical treatment for pathologies of the distal esophagus and proximal stomach method, it is necessary to compare the efficiency and safety profiles of these techniques in many parameters. The main indicators of the effectiveness of reconstructive operations after cardiectomy, are the frequency and severity of a large group of functional disorders characterized as “dumping syndrome” or “postgastrectomy syndrome”. A huge number of different types of anastomosis after cardiectomy has been proposed and studied. Nevertheless, an an objective evaluation of the results of these anastomosis types’ use, indicates that the hopes placed on them did not come true in most cases. It indicates insufficient coverage of this problem in scientific literature, despite the continuing interest of surgeons.

Gastric Accommodation Influences Proximal Gastric and Total Gastric Emptying in Concurrent Measurements Conducted in Healthy Volunteers

Gastric emptying and gastric accommodation play roles in generation of upper gastrointestinal symptoms. Whereas, both functions have been measured simultaneously using MRI or 99mTc- SPECT methodology, correlation of these two functions has not been evaluated simultaneously using solid and liquid meals. To study relationships of whole or proximal stomach volumes to emptying, we concurrently measured postprandial gastric accommodation and emptying (over 4 hours) of a 111In-labeled mixed solid and liquid meal. A semi-automated method allowing selection of a segmentation threshold based on greyscale image was used to measure volume of the proximal half of stomach, defined as the top half of axial slices along the vertical length of stomach. A correction factor derived from phantom studies was applied for up-scatter from 99mTc to 111In window. Relationships of time to emptying 10, 25 50 and 75% of the meal to fasting and postprandial gastric volumes were evaluated using Spearman correlation. Whole stomach fed and accommodation volumes were significantly correlated with all gastric emptying times 10%, 25%, 50%. Proximal stomach fed volumes were similarly associated with 50% and 75% proximal gastric emptying. Fed proximal gastric volume was associated with 50% and 75% whole gastric emptying. Fed proximal accommodation volume was associated with 50% gastric emptying. Fasting gastric volumes were not significant determinants of emptying rates. In conclusion, postprandial gastric accommodation is significantly associated with the rate of gastric emptying, with higher gastric volumes associated with prolongation of emptying. Novel methods to measure proximal gastric accommodation and correct for radioisotope up-scatter are described.

The Evolution of the Definition and Diagnosis of Barrett Esophagus: A Historical Perspective

Historical definitions of Barrett esophagus (BE) have depended on 2 beliefs: the esophagus is a squamous lined tube and the stomach is a columnar lined sac. Norman Barrett, in 1957, recognized that columnar lining in the tubular esophagus was reflux-induced metaplasia of squamous epithelium, leading to the present definition of BE. Recent evidence that gastric overdistension results in acid exposure of distal esophageal squamous epithelium, causing progressive columnar metaplasia, damage to the lower esophageal sphincter, and dilatation of the abdominal esophagus. This is presently mistaken at endoscopy for proximal stomach. The future definition of BE will likely include intra-sphincteric BE.

Epithelial expression of Gata4 and Sox2 regulates specification of the squamous–columnar junction via MAPK/ERK signaling in mice

The squamous–columnar junction (SCJ) is a boundary consisting of precisely positioned transitional epithelium between the squamous and columnar epithelium. Transitional epithelium is a hotspot for precancerous lesions, and is therefore clinically important; however, the origins and physiological properties of transitional epithelium have not been fully elucidated. Here, by using mouse genetics, lineage tracing, and organoid culture, we examine the development of the SCJ in the mouse stomach, and thus define the unique features of transitional epithelium. We find that two transcription factors, encoded by Sox2 and Gata4, specify primitive transitional epithelium into squamous and columnar epithelium. The proximal–distal segregation of Sox2 and Gata4 expression establishes the boundary of the unspecified transitional epithelium between committed squamous and columnar epithelium. Mechanistically, Gata4-mediated expression of the morphogen Fgf10 in the distal stomach and Sox2-mediated Fgfr2 expression in the proximal stomach induce the intermediate regional activation of MAPK/ERK, which prevents the differentiation of transitional epithelial cells within the SCJ boundary. Our results have implications for tissue regeneration and tumorigenesis, which are related to the SCJ.

Mixed adenoneuroendocrine carcinoma of proximal stomach; a rare but sinister pathology

Mixed adeno-neuroendocrine carcinoma is a rare tumor of the gastrointestinal tract comprising of both epithelial and neuroendocrine components, each representing at least 30% of the tumor. Diagnosis is based on clinical evaluation, radiological findings, histopathological features in conjunction with immunostaining with specific neuroendocrine markers such as chromogranin, synaptophysin, CD56, and markers of epithelial differentiation such as cytokeratin, CDX2, and carcinoembryonic antigen. A 50-year-old female presented with a history of dysphagia, chest pain, anorexia, and significant weight loss with normal physical findings and baseline investigations. Upper Gastrointestinal endoscopy showed growth at the gastroesophageal junction involving cardia of the stomach. Histopathological examination of the resected mass showed both adenocarcinoma and neuroendocrine carcinomatous components each involving more than 30% of total mass examined. Identifying adenocarcinoma component admixed with a high-grade neuroendocrine component is significant as the prognosis and survival of patients differ from pure adenocarcinoma.

Atypical dysphagia with end-stage oesophageal disease 30 years post Angelchik device placement in a 72-year-old man

Here we describe an atypical presentation of progressive dysphagia in a 72-year-old man leading to frequent regurgitations over the course of 30 years. Investigations revealed a foreign body ring surrounding the proximal stomach and dilation of the oesophagus proximal to the gastro-oesophageal junction. An Angelchik device was extracted; however, the patient’s rapid deterioration prior to surgery, in addition to his severely dysfunctional oesophagus, required placement of a jejunostomy feeding tube. Device removal was complicated by prior abdominal surgery, necessitating a thoracic approach. This case offers guidance on the management of patients with Angelchik prostheses who develop similar complications, while drawing attention to the importance and difficulties of early, definitive diagnosis in oesophageal pathology such as achalasia and gastro-oesophageal reflux disease.

Quantification of gastric emptying caused by impaired coordination of pyloric closure with antral contraction: a simulation study

Proper coordination of gastric motor functions is required for healthy gastric emptying. However, pyloric function may be impaired by functional disorders or surgical procedures. Here, we show how coordination between pyloric closure and antral contraction affects the emptying of liquid contents. We numerically simulated fluid dynamics using an anatomically realistic gastrointestinal geometry. Peristaltic contractions in the proximal stomach resulted in gastric emptying at a rate of 3–8 ml min −1 . When the pylorus was unable to close, the emptying rate increased to 10–30 ml min −1 , and instantaneous retrograde flow from the duodenum to the antrum occurred during antral relaxation. Rapid emptying occurred if the pylorus began to open during the terminal antral contraction, and the emptying rate was negative if the pylorus only opened during the antral relaxation phase. Our results showed that impaired coordination between antral contraction and pyloric closure can result in delayed gastric emptying, rapid gastric emptying and bile reflux.