Andrew K. Roorda

Ectopic Breast Cancer: Special Treatment Considerations in the Postmenopausal Patient

A 70‐year‐old woman with congenital bilateral accessory nipples developed a clinical mass and pain in the left accessory breast tissue. Excision revealed a T2 invasive ductal carcinoma with an identifiable in situ component. No masses were present in the normal breast, and 9 years after surgery, radiation therapy, and tamoxifen there has been no recurrence either in the ipsilateral affected accessory or normal breast tissue.

Update on Foreign Bodies in the Esophagus: Diagnosis and Management

Foreign body impaction in the esophagus is an important emergency that carries significant morbidity and potential mortality. The most common cause of esophageal foreign body obstruction in adults is meat bolus impaction above a pre-existing distal esophageal (mucosal) ring, peptic or malignant esophageal stricture, or eosinophilic esophagitis. Immediate evaluation of the airway, assessment of the urgency of removal, radiological evaluation to localize the object, endoscopic or surgical retrieval, and subsequent monitoring for complications are essential steps in the management.

Radiofrequency ablation of Barrett's esophagus

ZusammenfassungGRUNDLAGEN: Barrett-Ösophagus (BE) besitzt ein erhöhtes Krebsrisiko und nimmt deutlich an Häufigkeit zu. Die Radiofrequenz-Ablation (RFA) stellt eine neue, vielversprechende Methode zur Barrett-Ablation dar. METHODIK: Übersicht zu RFA bei Barrett-Ösophagus (Literatur: PubMed, Abstrakts der wichtigen Gastroenterologen-Kongresse 2007 und 2008). ERGEBNISSE: RFA erlaubt eine wirksame Behandlung des BE (auch bei Dysplasie) und erzielt hohe Heilungsraten mit minimalen Komplikationen. Eine Normalisierung des pH-Wertes in der Speiseröhre (medikamentös oder chirurgisch) ist wichtig, um die Wirksamkeit zu verbessern und ein Rezidiv zu verhindern. SCHLUSSFOLGERUNGEN: RFA ist eine äußerst wirksame, endoskopische Methode zur Entfernung von BE (±Dysplasie) und wird wohl die erste Therapie der Wahl bei BE werden. Wir benötigen aber weitere Daten, die den Stellenwert von RFA im Vergleich zu anderen Therapieoptionen vergleichen.SummaryBACKGROUND: Barretts esophagus (BE) is an important risk factor for esophageal carcinoma and its incidence is likely rising. Amongst the various available endoscopic ablative therapies, radiofrequency ablation (RFA) is a very promising new one. METHODS: We performed a comprehensive review of the literature on the treatment of BE using RFA. We searched for published articles on Pubmed and also reviewed the abstracts from the major gastroenterological society meetings of 2007 and 2008. RESULTS: RFA is an effective option in treating BE, especially when dysplastic changes are present, achieving high eradication rates with minimal complications. Prior control of intra-esophageal pH by either pharmacologic therapy or fundoplication is important in maximizing efficacy and preventing relapse. CONCLUSIONS: RFA is a very well tolerated therapy for non-dysplastic and dysplastic BE and will likely become a first-line treatment. More data, however, will be needed to compare the various existing modalities of endoscopic ablative and resection therapies for BE.

Endoscopic approach to capsule endoscope retention

In recent years, wireless capsule endoscopy has become increasingly indicated and utilized in the diagnosis and management of small bowel disorders. As such, its most common complication, capsule retention, has become a more frequently encountered clinical entity. Historically, when medical management of capsule retention has failed, patients have been sent directly to surgery. However, recent advances in small bowel enteroscopy have demonstrated a high success rate and safety profile in retrieving retained capsules. These approaches appear to be a viable alternative to surgery in many clinical scenarios. This article discusses both standard and advanced endoscopic approaches to capsule retention, and presents an algorithmic approach to their utilization.

Indications and safety of proton pump inhibitor drug use in patients with cancer

Introduction: Although the exact prevalence of proton pump inhibitor (PPI) use in cancer patients is not known, it is generally perceived to be widespread. PPIs are generally well tolerated and carry an excellent safety profile. However, increasing and longer term PPI use has raised concerns about the risk of pneumonia, bone fractures and enteric infections, and a possible interaction with clopidogrel that could increase the risk of cardiovascular events. Areas covered: We conducted a PubMed search of English language articles addressing the safety and adverse events associated with PPI use with particular emphasis in cancer patients. Expert opinion: PPIs, frequently used in cancer patients, are generally well tolerated and carry an excellent safety profile. PPI-induced acid suppression may increase the risk of Clostridium difficile or other enteric infections, nutritional deficiencies and community acquired pneumonia, all particularly important in cancer patients. The indications for PPI use in cancer patients should be carefully reviewed prior to use.

Circumferential and focal radiofrequency ablation for the treatment of Barrett's esophagus.

This invited profile summarizes the technical aspects and clinical trial results related to the use of circumferential and focal radiofrequency ablation in the management algorithm for Barrett’s esophagus. What makes this relatively new endoscopic intervention unique is its promising safety and efficacy profile reported in published clinical trials. This technology appears to have overcome many of the limitations of prior endoscopic ablative modalities, and is thus garnering a role in the management of this disease state.

AN ANALYSIS OF STANDARDS FOR ANTACID SIMETHICONE DEFOAMING PROPERTIES

The US Pharmacopeia XXII standard test method was used to measure the defoaming properties of simethicone antacid products. It was found that two pharmaceutical products did not meet the standards. Differences in defoaming activity were found when a bicarbonate solution was used in place of the acid solution specified by the test, and when the particle size of the tablets was varied. In general, the defoaming properties were reduced in the bicarbonate solution and when particle size was increased. These conditions more accurately reflect physiologic conditions than do the US Pharmacopeia Standards.

An elusive cause of severe gastrointestinal bleeding.

A 53-year old Filipino-American man with a history of recurrent episodes of rectal bleeding was initially evaluated in the emergency department with chief complaint of painless passage of dark red blood per rectum. He was in good health until 4 months prior to admission, at which time he was evaluated in the emergency room for hematochezia and hemoglobin of 7.5 g/dl. His past history was otherwise significant for hyperlipidemia and hypertension. He had an appendectomy 10 years prior to admission. He had been a smoker and alcoholic but had quit both 10 years previously. He worked as a caregiver in an assisted living facility. Endoscopy revealed long-segment Barrett’s esophagus and a small hiatal hernia but no active bleeding. Although fresh blood was noted throughout the colon and terminal ileum by colonoscopy, no active source of bleeding was identified. Gastrointestinal bleeding continued and was treated with intravenous fluids and 10 units of packed red cells. A second colonoscopy performed for persistent bleeding did not reveal any blood in the colon. A CT scan, Meckel’s scan (Fig. 1), and an abdominal angiogram, were all negative. Eventually his bleeding stopped, he became hemodynamically stable and was discharged. A week later, capsule endoscopy was normal except for delayed passage into the cecum. Despite such an extensive evaluation, the cause of this massive GI bleed remained elusive. Two months after the initial episode, he was re-evaluated in the emergency department for an abrupt episode of bloody diarrhea and hemoglobin of 8.4 g/dl. He required intravenous fluids and blood resuscitation with proton pump inhibition. The bleeding stopped spontaneously with hemoglobin stabilizing at 9.7 g/dl. Endoscopy again showed long-segment Barrett’s esophagus. A trans-anal double balloon enteroscopy revealed old blood in the distal 100 cm of ileum but no active lesions in the ileum or colon. He was discharged without a definitive diagnosis. He was doing well until one day prior to the current admission when he had a sudden onset of diarrhea along with dark bleeding per rectum. He denied any abdominal pain, nausea or vomiting, weight loss, or changes in appetite. On examination, he appeared anicteric and afebrile but in mild distress. His pulse was 132/min, respiration 20/min, blood pressure 120/83 mmHg without orthostatic signs; oxygen saturation by peripheral pulse oximetry was 100 % while breathing room air. Physical examination revealed a soft, non-tender abdomen with positive bowel sounds. There was no organomegaly or masses. Hemoglobin was 8.3 g/dl; comprehensive metabolic panel was normal. He was stabilized with intravenous fluids and two units of packed RBCs. Urgent abdominal multidetector CT angiography revealed active hemorrhage from a small bowel loop in the left lower quadrant (Fig. 2). Because repeat angiography was negative, no radiological intervention was possible. Because of the inconclusive evaluation up to that point he underwent laparoscopic exploration. At laparoscopy, adhesions were found in the right lower quadrant at the site of his previous open appendectomy. A Meckel’s diverticulum was identified in the jejunum S. Kommareddy A. K. Roorda P. Legha C. Lombard G. Triadafilopoulos El Camino Hospital, Mountain View, CA, USA

A fellow's guide to generating the endoscopy procedure report

As a gastroenterologist, you will be generating endosopy procedure reports for the rest of your career. Fellowhip is the time to learn to do it right. A good report, ntelligently composed, will speak volumes about you as n endoscopist; a poor report, on the other hand, may onvey, correctly or incorrectly, sloppiness in your work. heck out what Drs. Roorda and Triadafilopoulos have to hare with you regarding this essential skill to develop uring the fellowship. And, oh yes, don’t forget to proofead your report and take care of those typos!

Do pH and Temperature Play a Role in Gastrostomy Tube Deterioration

The effects of pH and temperature over time on percutaneous endoscopic gastrostomy (PEG) tube longevity were examined in an in vitro model. Two sets of tubes were obtained from 7 major US PEG manufacturers. Using scissors, each PEG tube was cut cross-sectionally 8 cm from the bumper end of the tube. Both qualitative (photographs) and quantitative (mass) measurements were taken at baseline. Median physiologic gastric acidity was approximated by completely submerging 1 set of each cut PEG tube in a 250-mL glass jar containing a 0.050-N (pH 1.3) solution of hydrochloric acid. As a control, another set of each PEG tube was completely submerged in a 250-mL glass jar containing a buffer solution of pH 6. Each jar was then submerged in the waterbath so that the water completely covered the tube but did not enter the jar. The waterbath was covered and maintained at a constant temperature of 37 degrees C. Measurements taken at baseline were repeated at 168 days and again at 375 days. On qualitative examination, no dilations, brittleness, obstruction, nodularity, tears, loss of elasticity, color changes, tube fracturing, kinking, loss of resilience, or variation in external diameter was observed. Quantitative examination showed no change in mass. Tubes removed from the pH 1.3 solution appeared identical to the tubes removed from the pH 6 solution. In all cases, there were no apparent changes from baseline. These findings suggest that temperature and pH can be excluded as predominant factors in tube deterioration and lend further support to a microbial hypothesis of PEG tube deterioration.