No abstract

An 86-year-old man with a past medical history of squamous cell carcinoma of the larynx and total laryngectomy with tracheostomy presented for evaluation of severe iron deficiency anemia (hemoglobin of 6.4 g/dL). Our patient had no upper gastrointestinal symptoms and underwent upper endoscopy. Upon slowly endoscopic withdrawal, a foreign body in the upper esophagus was visualized. This looked like the bumper from a conventional percutaneous endoscopic gastrostomy (Figure A). Careful investigation of the patients' medical records revealed that 2 years ago, in March 2017, owing to odynophagia, he also underwent a gastroscopy with similar findings (Figure B). Moreover, he underwent a video-swallow study that demonstrated a normal swallowing mechanism without evidence of pooling of contrast or aspiration. In November 2018, the patient had a cervical and chest computed tomography san with no metastasis (Figure C, D). Correlating these clinical, endoscopic and radiological findings with the patient's history and background what is the diagnosis of the esophageal foreign body? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Question: A 61-year-old male born in Ethiopia with a past medical history of hepatitis B carrier, tuberculosis, arterial hypertension, and aortic valve replacement (on coumadin treatment since 2009), presented with epigastric pain radiating to the right upper quadrant. The pain worsened after meals and was accompanied with a weight loss of 5 kg in the last month. He had recently discharged from the Neurosurgery Department with dexamethasone treatment for subdural hygroma. On physical examination, the patient was afebrile with normal blood pressure and soft abdomen with diffuse mild tenderness. Initially, laboratory examination was remarkable for mild normocytic normochromic anemia 11.6 g/dL, mean corpuscular volume of 84.4, normal white cell count of 7800/mm 3 (normal range, 4500-11,000/mm 3) with absolute eosinophil count of 300/mm 3 (normal range, 0-700/mm 3), international normalized ratio of 10.8, albumin 18 g/L, C-reactive protein 111 mg/L (normal, <5), sodium 127 mmol/L, and potassium 3.5 mmol/L. All other biochemical tests, creatinine, liver enzymes, pancreatic enzymes, and HIV screening revealed normal findings. Twenty-four hours after his admission, the patient developed massive hematemesis. An urgent upper gastrointestinal (GI) endoscopy showed severe duodenitis in the bulbus continuing down to the second part of the duodenum accompanied by multiple ulcers covered with exudate (Figure A, B). The mucosa was bleeding to touch and no definite bleeding vessel was identified. Biopsies were taken from the lesions and he began proton pump inhibitor drip. Over the following 8 hours, he developed recurrent hematemesis and hypotension and computed tomography angiography revealed extensive damage to the proximal small bowel (Figure C, D). Because of the high surgical risk, a selective embolization of the gastroduodenal artery was performed (Figure E, F). Despite this approach the patient continued to bleed and required blood transfusions. Correlating these clinical and endoscopic findings with the patient's history and background.