Brandon Sprung

Esophageal Mucosal Calcinosis: A Rare Site of Gastrointestinal Mucosal Calcinosis

Patient: Male, 68 Final Diagnosis: Esophageal mucosal calcinosis Symptoms: Dysphagia Medication: — Clinical Procedure: Esophagogastroduodenoscopy Specialty: Gastroenterology and Hepatology Objective: Rare co-existance of disease or pathology Background: Gastrointestinal tract mucosal calcinosis (MC) tends to affect the gastric mucosa, while esophageal involvement is rare. Gastric MC may be seen with solid organ transplantation, use of aluminum-containing antacids or sucralfate, malignancy, and chronic renal failure. While the incidence of gastric MC in renal transplant patients undergoing gastric biopsy is common (between 15–29%), to our knowledge esophageal MC has only been previously reported 3 times. Case Report: A 68-year-old male dialysis-dependent end stage renal disease status-post deceased donor kidney transplant underwent an esophagogastroduodenoscopy (EGD) for dysphagia and diffuse esophageal wall thickening seen on imaging studies. EGD demonstrated diffuse, circumferential thick white esophageal plaques and mucosal friability. Esophageal biopsies demonstrated erosive esophagitis with basophilic calcium deposits within the fibrinopurulent exudate and squamous mucosa. Stains for fungal organisms and viruses were negative. A diagnosis of esophageal MC was made. Although the patient had a protracted postoperative course after transplantation, he had improvement of the esophageal wall thickening on imaging after transplantation. Conclusions: Esophageal MC is a rare phenomenon and all of the previously reported cases of esophageal MC, including our case, have been in patients with end stage renal disease who were on dialysis. Although prolonged hypercalcemia and hyperphosphatemia, an elevated calcium-phosphorus product, and associated underlying inflammation are likely key etiologic factors, the pathogenesis of esophageal MC is not fully understood and is likely due to multiple collective etiologies. Likewise, more reported cases are likely to increase our understanding of the clinical significance and management of this rare disorder.

Endoscopic Appearance of Rectal Spread of Squamous Cell Carcinoma.

A 44-year-old African-American woman with a personal history of a vaginal condyloma and no family history of colorectal cancer presented with several months of rectal bleeding, pruritus ani, and change in stool caliber. She was found to have a new iron-deficiency anemia. (a–c) Colonoscopy revealed innumerable scattered, firm, smooth nodules ranging in size from approximately 2 to 20 mm, from the anal verge to 20-cm insertion, some of which were umbilicated. (d) Biopsies revealed colonic mucosa infiltrated by sheets of malignant epithelial cells with evidence of squamous differentiation, consistent with squamous cell carcinoma.

An Unusual Cause of Gastritis

Department of Medicine, Division of Gastroenterology and Hepatology, and Department of Pathology and Laboratory Medicine, Surgical Pathology Unit, University of Rochester Medical Center-Strong Memorial Hospital, Rochester, New York 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 Question: An 82-year-old woman with chronic lymphoid leukemia receiving chemotherapy and pancreatic adenocarcinoma status post Whipple procedure, presented with a 1-week history of anorexia, abdominal pain, nausea, and vomiting. Laboratory evaluation was significant only for a platelet count of 73,000. Abdominal computed tomography scan did not reveal any etiology for her symptoms, which persisted despite conservative treatment with intravenous hydration and pain control. On hospital day 5, she developed worsening thrombocytopenia with acute transaminemia (alanine aminotransferase, 119; aspartate aminotransferase, 324) and leukocytosis. Viral hepatitis panel including hepatitis A, B, and C, herpes simplex virus, cytomegalovirus, and Epstein-Barr virus were negative. An upper endoscopy revealed small, hemorrhagic, irregular shallow ulcerations and erosions throughout the stomach (Figure A). She subsequently developed a vesicular rash on her face, chest, and abdomen on hospital day 10. The endoscopic biopsies revealed acute hemorrhagic gastritis (Figure B, C). She rapidly deteriorated with persistent shock and care was withdrawn. What is your diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. 106 107 108 Presented in abstract format at the American College of Gastroenterology annual meeting in 2014. 109 110 111 112 113 Conflicts of interest The authors disclose no conflicts.

Fear of the Unseen

As a young gastroenterologist, you may be faced with interval colon cancers or missed polyps at some point in your career. Due to variable lesion growth rates, there is inevitably an inherent miss rate of colonoscopy even if you use optimal examination techniques. The thought of missed polyps or cancers can be anxiety-provoking for young endoscopists, bringing with it the potential for significant medical and legal ramifications. In fact, colonoscopy represents the highest frequency of closed claims and indemnities among all endoscopic procedures [1]. Unfortunately, fear of litigation surrounding the development of interval colon cancers leads to overuse of colonoscopy for surveillance and inappropriate application of colorectal cancer surveillance guidelines, both of which are now tracked as part of your physician performance measures. In legal cases of missed or interval cancers, focus lies on determining whether the ‘‘standard of care’’ was met for the procedure in order to determine whether negligence occurred; if you practice within established standards of care, you will be a more difficult target for litigation. As trainees, we take comfort in knowing that the watchful eyes of our attending are there to see what we may not, at times even repeating the examination themselves. As training transitions into independent practice, those watchful eyes slowly fade, leaving us without this security. Fortunately, several established steps can be taken to ensure standards of care are met and thus protect your patients from the tragedy and you from the medicolegal ramifications of a missed polyp or cancer.