Apeksha Shah

Intramural Duodenal Hematoma with Acute Pancreatitis in a Patient With an Overt Pancreatic Malignancy

Intramural hematomas have rarely been associated with pancreatitis, and to date there is only 1 case report of an intramural hematoma occurring with pancreatic adenocarcinoma. We describe a patient who presented with gastric outlet obstruction secondary to a spontaneous intramural duodenal hematoma and was found to have a pancreatic adenocarcinoma on endoscopic ultrasound (EUS) after it was not visualized by computed tomography (CT).

Osteopontin splice variant as a potential marker for metastatic disease in pancreatic adenocarcinoma.

Osteopontin (OPN) is a phosphoprotein that activates pathways that induce cancer cell survival and metastasis. Our aim was to examine the expression pattern of OPN splice variants a, b, and c in fine‐needle aspirates and to determine their correlation with stage‐adjusted pancreatic ductal adenocarcinoma (PDA) survival.

High risk of acute pancreatitis after endoscopic ultrasound-guided fine needle aspiration of side branch intraductal papillary mucinous neoplasms.

Background and Objectives: Data on the risk of acute pancreatitis following endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of pancreatic cystic lesions are limited. The aim of our study was to evaluate the frequency of acute pancreatitis after EUS-FNA of pancreatic cysts and solid lesions, and determine whether there was a difference in pancreatitis risk in patients with side branch intraductal papillary mucinous neoplasms (SB-IPMN). Patients and Methods: A retrospective review of patients who underwent EUS-FNA of pancreatic cysts and solid lesions was performed. The primary outcome measure was development of acute pancreatitis after EUS-FNA. Factors associated with acute pancreatitis were examined by statistical analysis to determine independent predictors of acute pancreatitis. Statistical significance was determined at a P ≤ 0.05. Results: We identified 186 patients with pancreatic cystic lesions and 557 with solid lesions in which EUS-FNA was performed. The median size of the cysts was 19 mm (range: 10-66 mm). There were 37 IPMNs, 33 mucinous cystic neoplasms, 58 serous cysts and 46 pseudocysts and 12 solid-cystic ductal carcinomas. The majority of patients (75%) with solid lesions were diagnosed with adenocarcinoma. Patients with pancreatic cysts had a statistically greater frequency of developing pancreatitis after EUS-FNA when compared to those with solid lesions (2.6% vs. 0.36% respectively; P = 0.13). In patients with cysts, there were no statistically significant differences between the two groups (with and without pancreatitis) with regard to a cyst location, size of the cyst, and number of needle passes or trainee involvement. Patients with SB-IPMN had a statistically higher frequency of pancreatitis after EUS-FNA compared to those with other cyst types (8% vs. 1.3% respectively; odds ratio = 6.4, 95% confidence intervals = 1.0-40.3, P = 0.05). Discussion: Patients with SB-IPMN are at a higher risk of developing acute pancreatitis after a EUS-FNA. Alternative means of diagnosis such as magnetic resonance cholangiopancreatogram might be necessary to avoid risk of EUS-FNA.

Management of Inflammatory Fluid Collections and Walled-Off Pancreatic Necrosis

Opinion statementPancreatic fluid collections are a frequent complication of acute pancreatitis. The revised Atlanta criterion classifies chronic fluid collections into pseudocysts and walled-off pancreatic necrosis (WON). Symptomatic PFCs require drainage options that include surgical, percutaneous, or endoscopic approaches. With the advent of newer and more advanced endoscopic tools and expertise, minimally invasive endoscopic drainage has now become the preferred approach. An endoscopic ultrasonography (EUS)-guided approach for pancreatic fluid collection drainage is now the preferred endoscopic approach. Both plastic stents and metal stents are efficacious and safe; however, metal stents may offer an advantage, especially in infected pseudocysts and in WON. Direct endoscopic necrosectomy is often required in WON. Lumen apposing metal stents allow for direct endoscopic necrosectomy and debridement through the stent lumen and are now preferred in these patients. Endoscopic retrograde cholangiopancreatography with pancreatic duct exploration should be performed concurrent to PFC drainage in patients with suspected PD disruption. PD disruption is associated with an increased severity of pancreatitis, an increased risk of recurrent attacks of pancreatitis and long-term complications, and a decreased rate of PFC resolution after drainage. Ideally, pancreatic ductal disruption should be bridged with endoscopic stenting.

Undifferentiated Carcinoma with Osteoclast-Like Giant Cells of the Pancreas in a Patient with New Diagnosis of Follicular Non-Hodgkin's Lymphoma

Pancreatic tumors with osteoclast-like giant cells are rare, with only 50 cases published to date. We report a case of a 67-year-old male with a new diagnosis of follicular non-Hodgkins lymphoma with an incidental pancreatic body mass on abdominal imaging. Cytology from the pancreatic mass obtained via endoscopic ultrasound-directed fine-needle aspiration (EUS-FNA) revealed an undifferentiated carcinoma with osteoclast-like giant cells.

Sa1997 Osteopontin Splice Variant As a Potential Prognostic Marker for Pancreatic Adenocarcinoma

both the crypt-villus and cephalo-caudal intestinal axes. In normal mice fed AIN76A, pS6 staining was sporadic and focal along the cephalo-caudal axis in both villus and crypt epithelial cells. When fed NWD1, staining was more localized to villus cells and more homogeneous along the cephalo-caudal axis. A similar pattern was seen at 3 months in AIN76A fed mice when Notch signaling was inactivated. However, at 9 months staining became less intense and diffuse from villus to crypt. The combination of Notch inactivation and feeding NWD1 produced staining in both villus and crypt cells which was continuous along the cephalo-caudal axis, regardless of age. Conclusion: mTOR activation in the intestine is influenced by both dietary and genetic factors, and is heterogeneous among intestinal epithelial cells. Feeding of NWD1 long-term causes sporadic tumors and elevated mTOR signaling. Although inhibition of Notch signaling may decrease the probability of cell autonomous tumor development, long term effects include secretory cell hyperplasia, copious mucin secretion and inflammation, leading to dysplasia and tumor development, especially in mice fed purified diets. Thus, the increase in mTOR signaling with both higher risk diet and inhibition of Notch signaling, may link this pathway to tumorigenesis regardless of etiology.