Gastroenterology Case Studies

Below are a few case studies from Dr. Nowain we hope you will find educational.


Gastric Inlet Patch

Gastric inlet patch 1AB is a 28-year-old male who had constant throat irritation and a highly sensitive gag reflex. Prior to seeing me, he had visited an ENT doctor who, upon visual inspection of the larynx, felt that his current symptoms were from acid reflux (otherwise known as Laryngopharyngeal Reflux Disease or LPR). The ENT doctor placed him on high-dose of acid blocking medication two-times-a-day to treat the possible acid reflux, but after several months of therapy his symptoms failed to improve.

I performed an EGD (upper GI endoscopy) and found no evidence of acid reflux changes in the esophagus despite the fact that he had discontinued the acid blocking medications several weeks prior to this procedure. His stomach and small intestine were similarly unremarkable. However, we did discover a large (~2cm) gastric inlet patch in the top portion (proximal) esophagus, located just below the upper esophageal sphincter and the larynx/vocal cords. Biopsies of this area were taken and confirmed a patch of stomach tissue located in the upper esophagus.

Gastric inlet patch 2

A gastric inlet patch occurs in 3-5% of adults and is when stomach (gastric) tissue is aberrantly located in the upper portion of the esophagus. It typically occurs as our cells are dividing and migrating during development in the womb. The medical term for this is ectopy – a condition in which an organ or substance is not in its natural or proper place (such as an ectopic pregnancy that develops outside the uterus). These gastric inlet patches can be easily missed during endoscopy and require a slow withdrawal of the endoscope from the esophagus for more accurate detection. Narrow band imaging (a technique used to filter out certain bands of light in order to add contrast to the image visualized on the screen) can aid in the diagnosis.

Most patients with gastric inlet patches are asymptomatic, but symptoms can include throat irritation and heartburn/reflux symptoms because these patches can produce acid. Acid reflux is typically acid from the stomach refluxing up into the esophagus, but when gastric inlet patches are present and symptomatic, acid is being produced in the esophagus from the patch. Most gastric inlet patches are benign, but there are rare reports that these inlet patches may harbor precancerous changes and progress to adenocarcinoma. Current guidelines state that if the original biopsies of the gastric inlet patch do not reveal precancerous changes, there is no need for follow-up surveillance or for ablation, as these rarely progress to cancer.

Gastric inlet patch 3Radiofrequency ablation is a procedure where a probe at the end of the endoscope is used to burn or ablate the gastric inlet patch, allowing normal esophagus tissue to regrow in this area. In patient AB’s case, the decision was made to perform radiofrequency ablation given that the patient had severe symptoms that did not improve with a high dose of acid blocking medication. Barrx radiofrequency ablation of the lesion was successfully performed and, after a short recovery period (consisting of throat pain that was easily managed with topical and oral pain medications), the patient’s symptoms had completely resolved. He continues to do well without the use of acid blocking medications.

Gastric inlet patch 4


Colonoscopy and Hemorrhoid Band Ligation Therapy

Patient John presented with complaints of blood in his stools and frequent hard bowel movements. After a thorough history and physical examination in the office, he was found to have internal hemorrhoids. I recommended a colonoscopy to ensure that there is no other cause of bleeding.

His colonoscopy revealed a small polyp, which was removed, minimizing any future chance of colon cancer from developing. During the colonoscopy, it was confirmed that he has internal hemorrhoids as the source of his bleeding. After discussing the various treatment options with him, he ultimately decided to undergo hemorrhoid band ligation therapy. We discussed proper bowel habits at length, and I detailed ways of preventing hemorrhoids from returning.

After 3 sessions (each 2 weeks apart), his symptoms completely resolved. He had no complications, no pain, and did not miss a single day of work during his treatment course. I encouraged him to eat a high fiber diet and drink plenty of water every day to prevent his hemorrhoids from recurring. So far, he is 1-1/2 years out from his treatment and doing extremely well.


Upper Endoscopy and Lap Band Surgery Complication

J.B., a 76-year-old man, was referred to Dr. Nowain for burning and discomfort in the abdominal region over a period of four weeks.  Dr. Nowain performed a thorough physical examination and evaluated his medical history, which showed a history of coronary artery disease and obesity. J.B also underwent a lap band procedure in 2002 with a subsequent weight loss of 70 pounds.

Dr. Nowain asked him to see his cardiologist immediately, but tests revealed non-obstructive coronary arteries. Chest discomfort due to insufficient blood in the heart was not believed to be the cause of his pain. Next, Dr. Nowain recommended an upper endoscopy (EGD).  The EGD revealed an eroded gastric lap band in the lumen of stomach, and J.B. was referred for minimally invasive surgery. The gastric band was removed laparoscopically, and in follow-up, the patient’s symptoms had resolved.

Lap band eroded into lumen of stomach

Lap band surgery, or laparoscopic gastric banding, is the most commonly performed weight-loss surgery. Therefore, it is important for healthcare professionals to become familiar with its potential long-term complications. In this case study, the patient suffered from a complication that occurs in less than 2% of cases. Other long-term complications include pouch enlargement (resulting in insufficient weight loss or weight gain) and band slippage. Band slippage is a condition that occurs in less than 2% of patients. The stomach wall slips through the band resulting in a bulge above the band, which can cause acute pain, nausea, and vomiting.

Dr. Nowain has a special interest in medical, surgical, and endoscopic methods for weight loss and has had a great deal of experience working closely with pre- and post-surgical patients who suffer from obesity.


Polyp Removal Techniques

Patient A.R. is a 46-year-old female who was presented to Dr. Nowain with the complaint of blood in her stools over the past several months. Through several steps, Dr. Nowain was able to determine that she had precancerous colon polyps that needed to be removed.

On examination in the office, she was noted to have internal hemorrhoids. She underwent band ligation with improvement of her bleeding symptoms. During that office visit, I explained to her that because hemorrhoids are very common in the general population (roughly 50 percent of people have them), it is important to make sure that there is no other source of bleeding in the lower GI tract. To ensure this, Dr. Nowain performed a colonoscopy two weeks after her band ligation therapy.

During her colonoscopy, our GI doctor found a 1.5 cm polyp in the lower rectum, which is the last part of the colon. Normal saline was injected at the polyp site to lift the tissue off of the outer rectum lining. This technique is commonly used for large polyps in order to prevent complications from occurring. A snare (small device which is passed through the scope and is able to lasso polyps) was used to remove the polyp in its entirety.

The polypectomy site was inspected to ensure that the polyp was completely removed and that there was no bleeding. The colon polyp was retrieved and sent to pathology for further evaluation under the microscope. Three days later, the results of the pathology analysis revealed that the colon polyp was a tubular adenoma with low-grade dysplasia. This is a precancerous polyp that, if not removed, could potentially develop into colon cancer. By removing this polyp during her colonoscopy, her chances of developing colon or rectal cancer are significantly diminished.

The patient did very well after the colonoscopy and returned to our gastroenterology office one week later for her biopsy results as well as further band ligation of her hemorrhoids. After three hemorrhoid bandings, the bleeding she originally complained of completely resolved. Based on the pathology and size of her polyp, Dr. Nowain recommended that she have a surveillance colonoscopy performed in three years to ensure that no new polyps develop.

When dealing with precancerous colon polyps, it is important for the pathologist to distinguish between low grade and high-grade precancerous changes. The progression of normal tissue to colon cancer occurs in a well-described series of steps:

  1. Normal tissue
  2. Low-grade precancerous changes
  3. High-grade precancerous changes
  4. Colon cancer

This case study emphasizes the importance of colonoscopy for colon cancer screening. It also highlights the importance of performing colonoscopy to prove that the source of rectal bleeding is coming from internal hemorrhoids.

Colon Polyp

1.5 cm polyp in the rectum.

saline injection to colon polyp

Needle used to inject saline underneath the polyp to raise it off of the outer lining of the rectum to prevent complications of polyp removal

Snare colon polyp removal

Snare used to remove the polyp.

Polypectomy

Polypectomy site after polyp removed confirms complete removal; area observed to ensure that there is no bleeding.

microscopic view of colon polyp

Microscopic view of polyp confirms that it is a precancerous polyp (tubular adenoma) with low-grade precancerous changes (low grade dysplasia).

Please contact us today at 310-657-4444 with any questions.