Giulio Cariani

Composite Gastric Carcinoma and Precursor Lesions with Amphicrine Features in Chronic Atrophic Gastritis

A composite carcinoma of the gastric body consisting of endocrine and mucous epithelial cells with interspersed amphicrine cells is reported together with ultrastructural and immunocytochemical documentation of endocrine and nonendocrine differentiation. The tumor was associated with hypergastrinemia related to chronic atrophic gastritis (achlorhydria) and with multiple proliferative lesions, such as intramucosal microcarcinoid (IMC) and endocrine cell proliferations of the micronodular and linear type, which are currently regarded as carcinoid precursor changes. Ultrastructurally, a composite architecture with amphicrine features was demonstrated in the primary tumor, IMC, and liver metastases. On the other hand, the endocrine cell proliferations exclusively contained gastrin and enterochromaffinlike cells. Immunostaining with antibodies to calcitonin documented a number of positive cells both in the primary and in the metastatic sites. This is the first report of mixed exocrine-endocrine-amphicrine components both in a metastasizing carcinoma and in its precursor lesions in a chronic hypergastrinemic state. Unlike previously reported lesions, the endocrine component was unexpectedly composed of calcitonin cells, which are not usually present in the gastric mucosa.

Therapeutic management and clinical outcome of autoimmune pancreatitis

Abstract Background. Autoimmune pancreatitis, in comparison to other benign chronic pancreatic diseases, is characterized by the possibility of curing the illness with immunosuppressant drugs. The open question is whether to differentiate autoimmune pancreatitis as a primary or secondary disease based on the presence or absence of other autoimmune diseases or whether to consider autoimmune pancreatitis a clinical and pathological systemic entity, called IgG4-related sclerosing disease, since this aspect is also very important from a therapeutic point of view. Methods. In this paper, we reviewed the conventional therapeutic approach used to treat autoimmune pancreatitis patients and the clinical outcome related to each treatment modality. We also reviewed some aspects which are important for the correct management of autoimmune pancreatitis, such as the surgical approach, the outcome of surgically treated autoimmune pancreatitis patients, whether medical treatment is always necessary, and, finally, when medical treatment should be initiated. Conclusions. Steroids are useful in alleviating the symptoms of the acute presentation of autoimmune pancreatitis, but some questions remain open such as the dosage of steroids in the acute phase and the duration of steroid therapy; finally, it should be assessed if other immunosuppressive non-steroidal drugs may become the first-line therapy in patients with AIP without jaundice and without atrophic pancreas.

Influence of K-ras status and anti-tumour treatments on complications due to colorectal self-expandable metallic stents: A retrospective multicentre study

BACKGROUND This study aimed to explore the relationship between K-ras status, anti-tumour treatments, and the complications of colorectal self-expandable metallic stenting in colorectal cancer. METHODS This is a retrospective, multicentre study of 91 patients with obstructive advanced colorectal cancer palliated with enteral stents between 2007 and 2011. RESULTS K-ras wild-type tumours were diagnosed in 44 patients (48.4%); 82 (90.1%) received chemotherapy and 45 (49.4%) had additional biological therapy (34 bevacizumab, 11 cetuximab). Twenty-one (23.1%) experienced stent-related complications: 11 (52.4%) occurred in the K-ras mutant group (P=0.9). K-ras wild-type patients were not less likely to develop adverse events than K-ras mutant patients (OR, 0.99; 95% CI: 0.4-2.7). Overall mean time to complication was 167.6 days (range 4-720 days), with no difference between the two groups (141 vs. 197 days; P=0.5). Chemotherapy did not influence the risk of complications (OR, 0.56; 95% CI: 0.14-2.9), and there was no evidence that patients treated with chemotherapy and cetuximab were more likely to experience stent-related complications than patients treated with chemotherapy alone, or untreated (OR, 1.2; 95% CI: 0.2-5.9). Although perforation rates were higher with bevacizumab-based treatment (11.8% vs. 7%), this result was not statistically significant (P=0.69). CONCLUSIONS K-ras mutation status, chemotherapy, and biological treatments should not influence colorectal stent-related complication rates.

Reliability of endoscopic ultrasound in predicting the number and size of common bile duct stones before endoscopic retrograde cholangiopancreatography

BACKGROUND Endoscopic ultrasound (EUS) is accurate for the diagnosis of choledocholithiasis; however, data are lacking regarding the prediction of stone number and size. AIMS To evaluate the concordance between EUS and endoscopic retrograde cholangiopancreatography (ERCP) in stone number and size assessment. METHODS We performed a retrospective analysis of consecutive patients undergoing ERCP due to detection of choledocholithiasis by EUS. Concordance between EUS and ERCP was defined as difference in stone diameter <30% and perfect match in stone number. RESULTS Among 116 patients, 25% had sludge, 37.9% had single and 37.1% had multiple stones. Overall concordance was 62.9%. Sludge was correctly assessed in 85.7%, single stone in 81.3% and multiple stones in 45.1% (P=0.0001). EUS was accurate in 78.8% of patients who underwent both procedures in the same session, but only in 61.9% in those who underwent ERCP within 1 week. Multivariate analysis identified the single-session approach (odds ratio 2.894; P=0.035) and multiple stones (odds ratio 0.244; P=0.001) as independent predictors of concordance. CONCLUSIONS Concordance between EUS and ERCP was correlated to the single session approach and inversely correlated to the presence of multiple stones. EUS may predict potentially difficult ERCP allowing to plan the best treatment strategy.

Combined technique (adrenaline injection plus endoloop) versus single technique (adrenaline injection) in the prevention of postpolypectomy bleeding in large pedunculated colonic polyps.

Combined Technique (Adrenaline Injection Plus Endoloop) Versus Single Technique (Adrenaline Injection) in the Prevention of Postpolypectomy Bleeding in Large Pedunculated Colonic Polyps

Painless Jaundice: Remember Alcohol and Smoking Habits for the Diagnosis

Question: A 75-year-old man with a history of chronic obstructive pulmonary disease was admitted to the hospital with a cough and mild dyspnea that was resolved quickly. He had a history of alcohol consumption (70 g of pure alcohol consumption daily from 30 years of age) and ex-smoker (40 cigarettes per day from 25 years of age until 68 years of age). He had a compensated diabetes (diagnosis made at the age of 62 years) and he was on metformin therapy. During hospitalization, the patient became jaundiced without any other symptoms; on physical examination, the abdomen was normal. Laboratory investigations revealed hyperbilirubinemia (total bilirubin, 9.5 mg/dL, mainly conjugated: 7.8 mg/dL), elevated serum concentrations of aspartate aminotransferase (116 IU/L; reference range, 0 –38), alanine aminotransferase (114 IU/L; reference range, 0 – 41), -glutamyl transferase (681 IU/L; reference range, 8 – 61), and alkaline phosphatases (347 IU/L; reference range, 0 –280). The total leukocyte count (7600 mmc) was within normal limits with neutrophilic predominance (68%). Serum amylase and lipase were also within the normal respective reference limits. Abdominal computed tomography was performed (Figure A). This examination showed a stone impacted in the papilla and a dilatation of both the common bile duct and the main pancreatic duct. Multiple calcifications were present in the head of the pancreas. No gallstones were seen. What is the most likely diagnosis?

Gastric argyrophil carcinoid and parathyroid adenoma: an unusual endocrine neoplasm association

Objective: Description of a patient who developed a gastric argyrophil carcinoid tumour, against a background of marked achlorhydria-related hypergastrinaemia, and who went on to develop a parathyroid adenoma 2 years later. Design: A single patient case report and review of the literature. Setting: Department of Medicine and Pathology at a University Hospital. Intervention: Surgical therapy. Conclusion: Parathyroid glands should be examined in all patients with gastric argyrophil carcinoid and, conversely, gastric status should be established in patients with hyperparathyroidism.

Antral gastrin cell hyperfunction in children

Objective: A description of the clinical history, diagnosis and management of a child with antral gastrin cell hyperfunction. Design: Detailed studies of hormonal, endoscopic and morphologic patterns. Setting: Gastrointestinal endocrinology section of a university hospital. Patient: A 14-year-old boy who complained of two episodes of acute upper gastrointestinal bleeding due to duodenal ulcer. Interventions and outcome measures: H2-antagonist therapy. Conclusions: Antral gastrin cell hyperfunction can be an underlying cause of peptic ulcer in children. The diagnosis is made by basal and protein meal-stimulated serum gastrin levels. Long-term H2-antagonist treatment is suggested.