Denzil Etienne

Atypical Presentation of Gastric Volvulus

Gastric volvulus has been reported in all age groups; however, it is typically diagnosed in the elderly. Organo-axial volvulus is the most common type, followed by the mesentero-axial and the combined types. Depending on the etiology, gastric volvulus can also be classified as primary (idiopathic) or secondary. Treatment of acute gastric volvulus involves laparoscopic or endoscopic procedures/maneuvers, depending on the severity of symptoms and surgical eligibility of the patient. Chronic gastric volvulus is typically managed conservatively, although laparoscopic or endoscopic interventions can also be employed depending on the severity of presentation.

Imatinib-induced Hepatitis in a Patient Treated for Gastrointestinal Stromal Tumor: A Rare Adverse Effect

Gastrointestinal stromal tumors (GISTs) are rare neoplasms of the digestive tract. The clinical behavior of GISTs varies greatly, has extended follow-up, and almost all of the tumors have malignant potential. The introduction of imatinib has led to extraordinary improvements in the treatment of individuals with GISTs (as well as those with Philadelphia chromosome-positive chronic myeloid leukemia (CML) and Philadelphia chromosome-positive acute lymphoblastic leukemia (ALL)). However, there have been notable postmarketing reports of adverse drug reactions of hepatotoxicity with the use of imatinib. By our search, among individuals taking imatinib for the treatment of GIST, only six cases of drug-induced liver injury (DILI) have been reported. Here, we present an interesting case of an elderly woman who developed DILI after taking imatinib for the treatment of GIST. As the liver function tests (LFTs) initially did not improve, it was decided to proceed with an interventional radiology (IR)-guided liver biopsy, which showed a histologic pattern of acute hepatitis, consistent with DILI. Ultimately, discontinuation of the antineoplastic agent led to recovery in the patient’s clinical condition along with normalization of her LFTs over the next several weeks. Thus, it is essential that physicians remain alert for and suspect DILI for any patient being treated with imatinib who presents with a sudden elevation of LFTs. The key to making the diagnosis is stopping the offending agent and closely monitoring the liver enzymes for improvement. When discontinuation of imatinib alone does not lead to improvement in LFTs and the patient’s clinical status, a detailed history should be taken and initial diagnostic testing performed to exclude other etiologies. And, if they are negative, a liver biopsy should be considered.

Through-the-scope endoscopic balloon dilatation of a nonsteroidal anti-inflammatory drug-induced diaphragm-like colonic stricture

A 56-year-old woman with a history of sciatica, who had been taking nonsteroidal anti-inflammatory drugs (NSAIDs) for one year complained of abdominal fullness, rectal bleeding, and decreased stool caliber for the past six months. An endoscope could not be extended beyond a stenosed region within the descending colon. This narrowed area appeared suggestive of a diaphragm-like stricture and was surrounded by areas of healed colitis and fibrosis (Fig. 1). Biopsies revealed lamina propria fibrosis with eosinophilic infiltration (Fig. 1). A through-the-scope sequential balloon dilator (Fig. 2) was used to dilate the stricture (Fig. 2) and an endoscope was subsequently advanced into the cecum, which revealed no further colopathy. The patient tolerated the procedure well; she was advised to avoid NSAIDs, and upon follow up she reported resolution of her symptoms. Colonic diaphragm-like stricture disease was first reported in 1989. An estimated 50 cases have been described in the last 10 years. Most cases were linked to long-term use of NSAIDs [1,2]. The pathophysiology of NSAID-induced colonic strictures is still not clear, but some studies attribute fibrosis to local toxic effects of NSAID preparations on mucosal integrity due to inhibition of protective prostaglandins [3]. Colonic diaphragm-like strictures should be considered in the

Gerald Klatskin (1910–1986): A pioneer in hepato-biliary disorders and biopsy techniques

The widespread use of liver biopsies underscores its utility and significance within the field of medicine. Dr. Gerald Klatskin’s pioneering work on liver biopsy techniques, as well as his study of liver histopathology, paved the way for its diagnostic and therapeutic applications around the world. His attention to detail as well as meticulous account of hilar cholangiocarcinoma has had a lasting impact on the medical community. Eponymously, the tumor was named after him—Klatskin’s tumor. Klatskin was also well known and respected for his commitment and devotion to his fellows who themselves went on to hold prestigious academic positions and make significant contributions of their own. The life and work of Klatskin documents a pioneering hepatologist and devoted teacher.

A Review of Double Common Bile Duct and Its Sequelae

A double or accessory common bile duct (ACBD) is a rare congenital anomaly. We report the case of a 60-year-old American Asian male, who was found to have a double or duplicated common bile duct after being admitted for evaluation of a pancreatic mass. A duplicated bile duct has the same mucosa histologically as a single bile duct. However, the opening of a duplicated bile duct lacks a sphincter allowing retrograde flow of gut contents which results in a higher probability of intraductal calculus formation. On rare occasions, it can predispose to liver abscesses, pancreatitis, pancreatic cancer, gallbladder cancer, gastric cancer, and ampullary cancer depending on the location of the opening of the ACBD. We present an integrative review of the limited cases of ACBD with correlation to the current case and discussion regarding the aspects of diagnosis and management.

Sclerosing mesenteritis:an uncommon cause of chronic abdominal pain

The mesentery is formed as a fold of the peritoneum that supports the intestine to the abdominal wall which contains numerous structures like blood vessels, nerves and the lymphatic system. Sclerosing mesenteritis (SM) is a rare disease of the mesentery characterized by chronic inflammation and fibrosis of the mesentery which was first described by Jura as “retractile mesenteritis” in 19241 and the term sclerosing mesenteritis was given by Emory et al.2 Only around 1200 cases have been reported3 however, the prevalence is thought to be around 0.6% and many cases remain undiagnosed.4 SM is known by various names some of which are Feiffer–Weber–Christian disease, Xanthogranulomatous mesenteritis, mesenteric lipodystrophy, retractile mesenteritis, sclerosing mesenteritis, liposclerotic mesenteritis, lipomatosis and lipogranuloma of the mesentery.1 We present a rare case of SM in a 50years old male who presented with abdominal pain.

Large Dermoid Cyst Presenting as Recurrent Pancreatitis

Pancreatic dermoid cysts are rare and benign congenital abnormalities of germ cell origin. They occur equally in males and females without age predilection. Though radiographic imaging aids in the diagnosis, most times they are inconclusive and require fine-needle aspiration cytology for confirmation. We report the first case of a dermoid cyst presenting as recurrent pancreatitis in a 49-year-old male. Computed tomography scan, followed by magnetic resonance imaging, showed a complex cystic mass lesion adjacent to the pancreatic tail. Endoscopic ultrasound noted a large heterogeneous cystic lesion with hypoechoic wall layers in the tail of the pancreas without invading surrounding structures. Fine-needle aspiration cytology revealed numerous mature squamous cells consistent with a pancreatic dermoid cyst. We discuss the history, clinical presentation, diagnosis, and treatment of pancreatic dermoid cysts.