Elie Chahla

Antiaging, longevity and calorie restriction.

Purpose of reviewThe role of calorie restriction in humans is controversial. Recently, new data in monkeys and humans have provided new insights into the potential role of calorie restriction in longevity. Recent findingsA study in rhesus monkeys showed a reduction in aging-associated mortality. A number of controlled studies have suggested a variety of beneficial effects during studies of 6–12 months in humans. Major negative effects in humans were loss of muscle mass, muscle strength and loss of bone. SummaryDietary restriction in rodents has not been shown to be effective when started in older rodents. Weight loss in humans over 60 years of age is associated with increased mortality, hip fracture and increased institutionalization. Calorie restriction in older persons should be considered experimental and potentially dangerous. Exercise at present appears to be a preferable treatment for older persons.

Testosterone replacement therapy and cardiovascular risk factors modification

Hypogonadism in males is associated with increased atherosclerotic disease. Physiologically, testosterone appears to have both positive and negative effects on the cardiovascular system. Testosterone decreases angina and may improve the cardiac healing response after myocardial infarction. Testosterone enhances function in males with heart failure (HF). Testosterone causes water retention and oedema is common in older persons. Oedema should not be used to diagnose HF in older persons. Studies in older persons with HF and frailty have shown a non-statistically lower mortality rate compared to those receiving placebo.

Role of endoscopic ultrasound-guided fine-needle aspiration cytology, viscosity, and carcinoembryonic antigen in pancreatic cyst fluid

Due to the advances and increased utility of abdominal cross-sectional imaging, the diagnosis of pancreatic cysts continues to increase. Many endosonographers, pancreatologists, and surgeons consider endoscopic ultrasound (EUS) to be an essential tool in the management of pancreatic cystic lesions (PCLs). EUS can help distinguish between mucinous and nonmucinous lesions and may identify the specific cyst type. EUS achieves these goals by delineating the cyst morphology, identifying high risk stigmata and worrisome features, and through image-guided fine-needle aspiration (FNA) and cyst fluid analysis. However, recent consensus statements have called to question the utility and diminished the role of EUS in this setting. The aim of this review is to assess the role and advances of EUS-FNA in pancreatic cyst fluid analysis, specifically in terms of fluid cytology, viscosity, and carcinoembryonic antigen (CEA) analysis.

Gastroduodenal Intussusception, Intermittent Biliary Obstruction and Biochemical Pancreatitis due to a Gastric Hyperplastic Polyp.

We present the case of a 76-year-old man with gastroduodenal intussusception secondary to a gastric hyperplastic polyp. Intussusception in the adult population occurs infrequently. Our patient presented with gastroduodenal intussusception, which is very uncommon and accounts for <10% of all types of intussusception. This case is unique in that partial endoscopic resection of the gastric hyperplastic polyp resolved the patients gastroduodenal intussusception, biliary obstruction and biochemical pancreatitis without the need for surgical intervention.

Frequency and Significance of Abnormal Pancreatic Imaging in Patients with BRCA1 and BRCA2 Genetic Mutations.

Objective. Pancreatic adenocarcinoma is typically diagnosed in advanced stages resulting in a significant reduction in the number of patients who are candidates for surgical resection. Although the majority of cases are believed to occur sporadically, about 10% show familial clustering and studies have identified an increased frequency of BRCA germline mutations. The role of screening for pancreatic adenocarcinoma in these populations is unclear. Our study aims to identify the abnormal pancreatic imaging findings in BRCA1 and BRCA2 mutation carriers. Methods. A retrospective review of patient medical records with known BRCA1 and BRCA2 mutations was conducted. Data was collected and all available abdominal imaging studies were reviewed. Results. A total of 66 patients were identified, 36 with BRCA1 and 30 with BRCA2 mutations. Only 20/66 (30%) had abdominal imaging (14 BRCA1 and 6 BRCA2 patients). Of those patients with abdominal imaging, abnormal pancreatic imaging findings were detected in 7/20 (35%) cases. Conclusion. Our study shows a high incidence of abnormal pancreatic imaging findings in patients with BRCA genetic mutations (35%). Larger studies are needed to further define the role of pancreatic cancer screening and the significance of abnormal imaging findings in BRCA1 and BRCA2 mutation carriers.

Esophageal Perforation Caused by Misplaced Minnesota Tube

48-year-old man with decompensated alcoholic Acirrhosis (Model for End-Stage Liver Disease 14) was admitted to an outside hospital with a 1-day history of hematemesis and melena. Upon arrival, the patient was hemodynamically unstable and his laboratory test results showed a hemoglobin level of 5.9 g/dL. Initial management included resuscitation with packed red blood cells and fresh-frozen plasma, in addition to combined continuous infusion of proton-pump inhibitor and octreotide therapy. An emergent esophagogastroduodenoscopy (EGD) was performed, which showed bleeding from distal esophageal varices. Four bands were placed successfully for endoscopic variceal ligation. Shortly thereafter, the patient had recurrent hematemesis and a repeat EGD proved unsuccessful in banding of a distal esophageal varix. The patient then was intubated for airway protection and a Minnesota tube was placed before transfer to our facility for further care. On arrival to our hospital, the patient’s respiratory status deteriorated acutely and a chest radiograph showed a misplaced Minnesota tube with the gastric balloon inflated within the distal esophagus (Figure A). Both gastric and esophageal balloons subsequently were deflated and the Minnesota tube was removed. A chest computerized tomography showed a new, large, left-sided pleural effusion concerning for hemothorax. Emergent chest tube placement was performed. An EGD showed a large esophageal perforation that tracked into the pleural cavity, extending from 29 to 39 cm from the incisors. Endoscopic placement of 2 fully covered (23mm 15 cm) esophageal metal stents (Boston Scientific, Galway, Ireland) was performed and a follow-up esophagogram showed no contrast extravasation (Figure B). Subsequently, a 10 mm 8 cm Viatorr (GORE, Flagstaff, AZ) transjugular intrahepatic portosystemic shunt was placed by interventional radiology. After a prolonged hospital course, the patient’s condition improved. Two months after presentation, a repeat EGD permitted removal of all stents and fluoroscopy confirmed complete closure of the esophagopleural fistula (Figure C). To prevent this complication, we recommend the following: (1) passage of the tube to at least 50 cm from the incisors, (2) injection of air into the gastric aspiration port while auscultating over the stomach, and (3) radiographic confirmation before complete inflation of the gastric balloon whenever possible.

Peritonitis following Endoscopy in a Patient on Peritoneal Dialysis with a Discussion of Current Recommendations on Antibiotic Prophylaxis.

Patients on peritoneal dialysis (PD) are at increased risk for peritonitis. We report a case of a patient with end-stage renal disease on continuous ambulatory PD (CAPD) who developed peritonitis within 24 h of upper endoscopy with biopsy and colonoscopy with polypectomy. He had a previous history of peritonitis unrelated to invasive procedures and eventually was transitioned to hemodialysis because of his recurrent peritonitis. The International Society for Peritoneal Dialysis (ISPD) and newly revised American Society for Gastrointestinal Endoscopy (ASGE) guidelines recommend prophylactic antibiotics for CAPD patients undergoing endoscopic procedures. Other guidelines do not address this issue, and there has been limited evidence to support recommendations.

A Unique Case of a Patient with Rectal Cancer Who Developed Benign Esophageal Stenosis after Localized Rectal Radiation and Systemic Chemotherapy

Acute esophagitis and esophageal strictures typically occur after local radiation therapy to the thoracic field. Toxicity is usually limited to the field of radiation and potentially augmented by concomitant use of chemotherapy, however esophageal stricturing due to chemotherapy alone is exceedingly rare. Gastrointestinal toxicity has been previously reported in the setting of 5-fluorouracil (5-FU)-based chemotherapy with abnormal thymidylate synthase or dihydropyrimidine dehydrogenase activities. We present a unique case of isolated chemotherapy-induced esophageal stricture in the setting of stage IIIa rectal adenocarcinoma which presented shortly after initiation of treatment with 5-FU-based chemotherapy in a patient with normal thymidylate synthase and dihydropyrimidine dehydrogenase assays. These findings prompt further investigation of pathways and potential risk factors leading to esophageal toxicity in patients treated with 5-FU-based chemotherapy.