Amir Kashani

Cap-assisted Endoscopic Mucosal Resection is Highly Effective for Nonpedunculated Colorectal Lesions.

Goals: To assess the safety and efficacy of cap-assisted endoscopic mucosal resection (C-EMR) for nonpedunculated colorectal lesions. Background: There are little data supporting the safety and efficacy of C-EMR for colorectal polyps. Study: A retrospective review was conducted on the medical records of 97 consecutive patients who underwent C-EMR for nonpedunculated colorectal lesions in a tertiary center by a single gastroenterologist (L.H.J.). Reported outcomes were: overall eradication rate that included all attempted C-EMRs, endoscopist-reported eradication rate that included C-EMRs reported as a success, and complications rate. Results: A total of 134 C-EMRs were performed on 124 nonpedunculated colorectal lesions within a 55-month period, with a median follow-up of 4.2 (1.6 to 46.8) months. Among the polyps with available follow-up, the overall eradication rate was 91% (81/89); the endoscopist-reported eradication rate was 98.8% (81/82). The complications rate was 10.2%: perforation (3.9%), intraprocedural bleeding (3.9%), and delayed bleeding (2.4%); all but 2 perforation cases that required surgical interventions (both occurring early in the time period in which procedures were performed), were treated endoscopically or conservatively with complete recovery. Conclusions: C-EMR is highly effective in treating nonpedunculated colorectal lesions, which can be learned and practiced in the appropriate setting. Decline in the complications rate was observed as the endoscopist gained experience. Although perforation remains a relatively high risk, this may be decreased by increasing the fluid cushion, and decreasing suction pressure. Immediate recognition and endoscopic management of perforation can be highly successful. C-EMR is our suggested method in approaching nonpedunculated colon polyps, especially flat polyps that are not easily accessible by other endoscopic techniques.

Spleen Size in Cirrhosis of Different Etiologies

The purpose of this study was to evaluate the impact of cirrhosis etiology on spleen size as measured by sonography and computed tomography (CT).

Liver metastasis from hepatoid adenocarcinoma of the esophagus mimicking hepatocellular carcinoma

Alpha-fetoprotein (AFP)-producing adenocarcinoma, histologically mimicking hepatocellular carcinoma (HCC), is a distinct entity known as hepatoid adenocarcinoma (HAC). Reported cases of HAC arising from the esophagus are extremely rare. Due to common liver metastasis and elevated AFP levels in patients with esophageal HAC, differentiation of HAC with liver metastasis from HCC could be challenging. We describe a case of esophageal HAC that presented with a liver mass showing hepatoid features and elevated serum AFP levels. Initial presentation was suspicious for HCC. Upon further diagnostic work-up, the patient was diagnosed with esophageal HAC with liver metastasis. The distinction between these two entities is particularly important because HAC is more aggressive, and its therapeutic options are very limited.

Leclercia adecarboxylata Bacteremia in a Patient with Ulcerative Colitis.

Patients with inflammatory bowel disease (IBD) are a high risk population for bacteremia. Derangement in the mucosal architecture of the gastrointestinal (GI) tract and frequent endoscopic interventions in immunocompromised individuals are considered primary causes. Isolation of opportunistic microorganisms from the bloodstream of IBD patients has been increasingly reported in recent years. Leclercia adecarboxylata is a ubiquitous, aerobic, motile, gram-negative bacillus. The human GI tract is known to harbor this rarely pathogenic microorganism. There are only a few case reports of bacteremia with this microorganism; the majority are either polymicrobial or associated with immunocompromised patients. We describe a case of monomicrobial L. adecarboxylata bacteremia in a 43-year-old female who presented with bloody diarrhea. Colonoscopy revealed diffuse colonic mucosal inflammation with numerous ulcers, and histopathology revealed crypt abscesses. Following an episode of rectal bleeding, two sets of blood cultures grew L. adecarboxylata, which was treated with intravenous ceftriaxone. After a complicated hospital course, she was eventually diagnosed with ulcerative colitis and enteropathic arthritis, treated with intravenous methylprednisolone, mesalamine, and infliximab which resulted in resolution of her symptoms. In our previously immunocompetent patient, derangement of the gut mucosal barrier was the likely cause of bacteremia, yet performing endoscopic intervention may have contributed to bacterial translocation.

Diagnosis of primary squamous cell carcinoma of the pancreas using endoscopic ultrasound-guided core needle biopsy

Primary squamous cell carcinoma (SCC) of the pancreas is a particularly rare entity. Diagnosis of this tumor is tentatively made after ruling out metastatic SCC from another primary site and adenosquamous carcinoma (ASC) of the pancreas. Here we discuss the case of a 76-year-old woman who was found to have a solitary pancreatic lesion and multiple hepatic lesions. Results of computed tomography-guided biopsy of the liver lesions were consistent with a metastatic carcinoma displaying squamous differentiation; therefore, an endoscopic ultrasound (EUS)-guided core-needle biopsy (CNB) of the pancreatic mass was performed. Meticulous histopathological examination of the pancreatic specimen at multiple levels revealed moderately well-differentiated SCC with no glandular component. An extensive metastatic work-up did not reveal an extra-pancreatic origin for this SCC; hence, a diagnosis of primary SCC of the pancreas was established. To our knowledge, this is the first report of the diagnosis of a primary SCC of the pancreas using EUS-guided CNB. We believe that CNB has a diagnostic yield equivalent to that of fine-needle aspiration for recognizing pancreatic adenocarcinoma; however, when cytological examinations reveal atypical squamous epithelial cells suggestive of malignancy, CNB may provide a better tissue specimen, from which to determine the presence of a glandular component. Such an assessment will differentiate pancreatic SCC from ASC.

Fecal Microbiota Transplantation in Inflammatory Bowel Disease: A Primer for Internists

Inflammatory bowel disease consists of disorders characterized by chronic idiopathic bowel inflammation. The concept of host-gut-microbiome interaction in the pathogenesis of various complex immune-mediated chronic diseases, including inflammatory bowel disease, has recently generated immense interest. Mounting evidence confirms alteration of intestinal microflora in patients with inflammatory bowel disease. Thus, restoration of normal gut microbiota has become a focus of basic and clinical research in recent years. Fecal microbiota transplantation is being explored as one such therapeutic strategy and has shown encouraging results in the management of patients with inflammatory bowel disease.

Metastatic Periampullary Tumor from Hepatocellular Carcinoma Presenting as Gastrointestinal Bleeding

Periampullary tumors constitute a number of diverse neoplastic lesions located within 2 cm of the major duodenal papilla; among these, metastatic lesions account for only a small proportion of the periampullary tumors. To our knowledge, a metastatic periampullary tumor from hepatocellular carcinoma has never been reported. A 62-year-old male reported to our institute for fatigue and low hemoglobin. His medical history was remarkable for multifocal hepatocellular carcinoma (HCC) treated with selective transcatheter arterial chemoembolization (TACE). An esophagogastroduodenoscopy (EGD) was performed which revealed a periampullary mass. Histopathology was consistent with metastatic moderately differentiated HCC. Two endoloops were deployed around the base of the mass one month apart. The mass eventually sloughed off and patients hemoglobin level stabilized. We postulated that periampullary metastasis in this patient was the result of tumor fragments migration through the biliary tracts and that TACE which increases tumor fragments burden might have played a contributory role. Metastasis of HCC to the gastrointestinal (GI) tract should be considered as a cause of GI bleeding.