Giovanni DePetris

Treatment of gastric antral vascular ectasia (watermelon stomach) with endoscopic band ligation

BACKGROUND Gastric antral vascular ectasia (GAVE) is characterized by mucosal and submucosal vascular ectasia causing recurrent GI hemorrhage. Treatment of GAVE with endoscopic thermal therapy (ETT) requires multiple sessions for destruction of vascular ectasia and control of bleeding. Endoscopic band ligation (EBL) has become the standard treatment of varices because it effectively obliterates the submucosal plexus of esophageal varices with an acceptably low rate of complications. Additionally, EBL has been used for control of bleeding from other GI vascular lesions. In patients with GAVE and recurrent GI hemorrhage, EBL may offer an alternative to ETT for treatment of large areas of diseased mucosa and submucosa. OBJECTIVE Our purpose was to compare EBL (n = 9) with ETT (n = 13) for the treatment of bleeding from GAVE. DESIGN Observational comparative study. PATIENTS Patients with gastric antral vascular ectasia with occult or overt bleeding. SETTING Mayo Clinic Arizona, a multispecialty academic medical center. INTERVENTION EBL or ETT with argon plasma coagulation or electrocautery. MAIN OUTCOME AND MEASUREMENTS Number of treatments to cessation of bleeding and posttreatment hemoglobin, hospitalization, and transfusion requirement. RESULTS There were no significant differences in the demographics, clinical presentation, associated portal hypertension, or mean hemoglobin values or the mean number of transfusions or hospitalizations between the 2 groups before treatment. Four patients in the EBL group had failed prior ETT. Compared with ETT, in exploratory statistical testing EBL had a significantly higher rate of bleeding cessation (67% vs 23%, P = .04), fewer treatment sessions required for cessation of bleeding (1.9 vs 4.7, P = .05), a greater increase in hemoglobin values (2.8 g/dL vs 0.9 g/dL, P = .05), a greater decrease in transfusion requirements (-12.7 vs -5.2, P = .02), and a greater decrease in hospital admissions (-2.6 vs -0.5, P = .02) during the follow-up period. Analysis of covariance showed significantly superior efficacy of EBL for cessation of bleeding, postprocedure transfusion, and hospitalization. One patient in the EBL group had postprocedure emesis and 1 in the ETT group had immediate post procedure bleeding. All patients in the EBL group had complete mucosal healing with minimal residual GAVE at follow-up endoscopy failed post-EBL. CONCLUSIONS Our initial experience suggests that EBL is superior to ETT for the management of GAVE. EBL required fewer treatment sessions for control of bleeding, had higher rates for cessation of bleeding, had a reduction in hospitalizations and transfusion requirements, and allowed for a significant increase in hemoglobin values.

T-Helper 2 Cytokines, Transforming Growth Factor β1, and Eosinophil Products Induce Fibrogenesis and Alter Muscle Motility in Patients With Eosinophilic Esophagitis

BACKGROUND & AIMS Patients with eosinophilic esophagitis (EoE) often become dysphagic from the combination of organ fibrosis and motor abnormalities. We investigated mechanisms of dysphagia, assessing the response of human esophageal fibroblasts (HEFs), human esophageal muscle cells (HEMCs), and esophageal muscle strips to eosinophil-derived products. METHODS Biopsy specimens were collected via endoscopy from the upper, middle, and lower thirds of the esophagus of 18 patients with EoE and 21 individuals undergoing endoscopy for other reasons (controls). Primary cultures of esophageal fibroblasts and muscle cells were derived from 12 freshly resected human esophagectomy specimens. Eosinophil distribution was investigated by histologic analyses of full-thickness esophageal tissue. Active secretion of EoE-related mediators was assessed from medium underlying mucosal biopsy cultures. We quantified production of fibronectin and collagen I by HEF and HEMC in response to eosinophil products. We also measured the expression of intercellular adhesion molecule-1 and vascular cell adhesion molecule-1 by, and adhesion of human eosinophils to, HEFs and HEMCs. Eosinophil products were tested in an esophageal muscle contraction assay. RESULTS Activated eosinophils were present in all esophageal layers. Significantly higher concentrations of eosinophil-related mediators were secreted spontaneously in mucosal biopsy specimens from patients with EoE than controls. Exposure of HEFs and HEMCs to increasing concentrations of eosinophil products or co-culture with eosinophils caused HEFs and HEMCs to increase secretion of fibronectin and collagen I; this was inhibited by blocking transforming growth factor β1 and p38 mitogen-activated protein kinase signaling. Eosinophil binding to HEFs and HEMCs increased after incubation of mesenchymal cells with eosinophil-derived products, and decreased after blockade of transforming growth factor β1 and p38 mitogen-activated protein kinase blockade. Eosinophil products reduced electrical field-induced contraction of esophageal muscle strips, but not acetylcholine-induced contraction. CONCLUSIONS In an analysis of tissues samples from patients with EoE, we linked the presence and activation state of eosinophils in EoE with altered fibrogenesis and motility of esophageal fibroblasts and muscle cells. This process might contribute to the development of dysphagia.

AJR Teaching File: Incidental Hepatic Mass

Received August 31, 2006; accepted after revision November 21, 2006. 1Department of Diagnostic Radiology, Mayo Clinic, 13400 E Shea Blvd., Scottsdale, AZ 85259. Address correspondence to A. C. Silva (silva.alvin@mayo.edu). 2Department of Laboratory Medicine and Pathology, Mayo Clinic, Scottsdale, AZ. AJR 2008;190:S62–S64 0361–803X/08/1906–S62

Isolated Supraclavicular Lymph Node Metastasis in Pancreatic Adenocarcinoma: A Report of Three Cases and Review of the Literature

CONTEXT Supraclavicular lymph nodes represent a rare site of metastasis in pancreatic cancer. We report three cases of pancreatic adenocarcinoma with metastases to supraclavicular lymph nodes. CASE REPORT A 51-year-old male was diagnosed with locally advanced pancreatic adenocarcinoma on computed tomography (CT) scan. He was recommended neoadjuvant chemotherapy followed by chemoradiation therapy. However, positron emission tomography (PET)/CT scans and subsequent fine needle aspiration cytology showed supraclavicular lymph node metastasis. The patient received systemic chemotherapy for metastatic pancreatic adenocarcinoma. The second patient, a 66-year-old female with pancreatic adenocarcinoma, underwent pancreaticoduodenectomy and was found to have peripancreatic lymph node involvement. She received adjuvant chemotherapy and was followed-up with surveillance CT scans, which did not reveal any metastasis. However, the patient complained of neck swelling. PET/CT scan and biopsy revealed supraclavicular lymph node metastasis from a pancreatic adenocarcinoma primary. The third patient, a 79-year-old male with a past history of thyroid carcinoma who was treated with partial thyroidectomy, developed neck swelling 4 years after his surgery. Fine needle aspiration cytology was consistent with known papillary thyroid carcinoma. Staging evaluations revealed a pancreatic mass for which he underwent subtotal pancreatectomy and splenectomy. Histopathology revealed grade 3 pancreatic adenocarcinoma. Excisional biopsy of a supraclavicular lymph node showed metastatic pancreatic adenocarcinoma. PET/CT results were consistent with these findings. CONCLUSION In patients with pancreatic adenocarcinoma, supraclavicular lymph node metastasis represents an uncommon, but clinically significant finding that can lead to changes in treatment planning. PET imaging represents a valuable tool in the detection and follow up of these patients.

Images of the Month: Gastric Pneumatosis Due to Sevelamer-Mediated Necrosis.

A 64-year-old-man with a history of end-stage renal disease (ESRD) who was on hemodialysis presented with bloody emesis and abdominal pain. Abdominal computed tomography showed gastric pneumatosis (left; arrows point to air in the posterior wall of the gastric fundus). Upper endoscopy revealed diffuse, severely ulcerative mucosa in the gastric body (center). Biopsy revealed sevelamer crystals (right; arrows), in the lamina propria of the body of the stomach. Notice the two-tone color, with a pale, brownish background and pink veins, defining the broad curved scales. Sevelamer is an anion-exchange resin used to treat hyperphosphatemia in ESRD patients. Sevelamer was discontinued, and the patient was treated with a proton pump inhibitor and a low-phosphate diet.

Images of the Month

An 80-year-old man who had had an esophagectomy for esophageal adenocarcinoma complicated by multiple dilations of the anastomosis presented with cardiogenic shock and abdominal pain following a repeat esophageal dilation.(a) A chest X-ray showed bowel loops in the left hemithorax. (b) Computed tomography showed a large hiatal hernia with distended stomach in the right chest, with the colon and small bowel occupying the left hemithorax, displacing the surrounding organs to the contralateral side. The loops caused an evolving tension colothorax leading to tamponade. The patient recovered after an emergent surgical reduction of the hernia and repair of the diaphragm.

115 Predicting Endoscopic and Histologic Remission in Adult Patients With Eosinophilic Esophagitis Using the EEsAI PRO Score

G A A b st ra ct s calculated at baseline and at week 12. Proximal and distal esophageal scores, total scores (summation of proximal and distal), and subscores for individual component of EREFS (edema, rings, exudates, furrows, stricture) were prospectively recorded. Baseline and followup EREFS scores were compared, and post-treatment eosinophil counts and EREFS scores were correlated. Data analysis was performed on the intent-to-treat population. Results: A total of 93 subjects were randomized from 25 centers, and 87 were included in the final analysis. 97% of subjects had endoscopic features identified at baseline. The OBS (n= 49) and placebo (n=38) groups did not differ in baseline demographic and endoscopic characteristics. EREFS scores significantly improved after treatment in both proximal (3.4 to 1.5; p<0.0001) and distal esophagus (4.3 to 2.4; p<0.0001) with OBS but not placebo (proximal 3.3 to 3.4; distal 3.6 to 3.9). Features of edema, rings, exudates and furrows showed significant improvement with OBS but not placebo (Figure). Strictures did not significantly change following OBS or placebo although subjects with high grade strictures were excluded from trial entry. Proximal, distal and total EREFS correlated with peak eosinophil counts after treatment (R: 0.35, p<0.0001). Conclusions: (1) This is the first study to utilize a validated endoscopic scoring instrument in a randomized controlled trial of medical therapy for EoE. (2) Significant benefit was demonstrated in the inflammatory (edema, exudates, furrows), ring, and total EREFS scores. (3) Significant correlation was demonstrated between EREFS and peak eosinophil counts. (4) Endoscopic outcomes may be important endpoints of EoE clinical trials that complement symptom and histologic assessments. Written on behalf of the MPI-101-06 Investigators.