Glenn Harvin

Sclerosing Mesenteritis: A Rare Cause of Small Bowel Obstruction

Sclerosing mesenteritis falls within a spectrum of primary idiopathic inflammatory and fibrotic processes that affect the mesentery. The exact etiology has not been determined, although the following associations have been noted: abdominal surgery, trauma, autoimmunity, paraneoplastic syndrome, ischemia and infection. Progression of sclerosing mesentritis can lead to bowel obstruction, a rare complication of this uncommon condition. We report a case of a 66-year-old female with abdominal pain who was noted to have a small bowel obstruction requiring laparotomy and a partial small bowel resection. The pathology of the resected tissue was consistent with sclerosing mesenteritis, a rare cause of a small bowel obstruction. Sclerosing mesenteritis has variable rates of progression, and there is no consensus regarding the optimal treatment. Physicians should consider sclerosing mesenteritis in the differential diagnosis of a small bowel obstruction.

Bouveret's Syndrome with Severe Esophagitis and a Purulent Fistula

Bouverets syndrome is a rare variant of gallstone ileus with an overall incidence of 1–3%. It is a rare cause of gastric outlet obstruction resulting from the passage and impaction of a large gallstone through a cholecysto-duodenal fistula. A combination of diagnostic modalities is often required for a diagnosis. Management options include endoscopy and surgery. The most commonly performed procedures are enterolithotomy or gastrostomy, either alone or with cholecystectomy and fistula repair. We describe a unique variant of chronic Bouverets syndrome with the unusual associations of severe esophagitis and a purulent fistula.

Colon Cancer Screening in North Carolina

Colorectal cancer (CRC) is the 2nd leading cause of cancer death both in North Carolina and in the United States. The goal of CRC screening is early detection and prevention. This commentary reviews the evidence for screening, discusses current screening options, and explores which options are best suited for use in North Carolina.

Airway observations during upper endoscopy predicting obstructive sleep apnea

Background This pilot study examined airway characteristics during upper endoscopy to determine who is at high risk for obstructive sleep apnea. Methods Patients undergoing routine upper endoscopy were divided into 2 groups according to the Berlin Questionnaire (high and low risk for sleep disordered breathing). Patients underwent routine upper endoscopy using propofol sedation. The airway was then evaluated for no, partial, or complete collapse at the levels of the palate/uvula/tonsils, the tongue base, the hypopharynx, and the larynx. They were given a score of 0 for no collapse, 1 for partial collapse, and 2 for complete collapse. The score for each of these levels was added to give a total score or severity index. The larynx was also evaluated for lateral pharyngeal collapse (minimal, up to 50%, >50%, or 100%). Results We found that patients with a partial obstruction at the level of the palate/uvula/tonsils, tongue base, hypopharynx, or larynx, or complete obstruction at any level more often had a positive Berlin questionnaire. Patients with a positive Berlin questionnaire were more often of increased weight (mean 197 vs 175 lbs, P=0.19), increased body mass index (31.2 vs 27.42 kg/m2, P=0.11), increased neck circumference (36.7 vs 34.7 cm, P=0.23), and had a higher total airway score (2.61 vs 1.67, P=0.09). Conclusions The results of our pilot study represent preliminary data regarding the use of upper endoscopy as a potential tool to evaluate patients for obstructive sleep apnea.

Adult-Onset Esophageal Crohn’s Disease

Crohn’s disease (CD) is an idiopathic inflammatory bowel disease that can involve any part of the gastrointestinal tract. Esophageal involvement is rarely seen in adults, especially at the initial diagnosis of CD. Esophageal symptoms as primary manifestations of the disease are extremely rare. We report a case of a CD with esophageal involvement at the time of her initial diagnosis of CD.

What Do We Need to Know About Colonic Polypoid Ganglioneuroma? A Case Report and A Comprehensive Review

Intestinal ganglioneuromas (GNs) are rare well-differentiated, slowly growing neuroectodermal neoplasms mainly formed of nerve fibers, ganglion cells, and supporting cells [1]. There are three types of GNs: polypoid GNs, ganglioneuromatous polyposis, and diffuse ganglioneuromatosis. Polypoid GNs are the most common type and are typically found incidentally on colonoscopies as a solitary polyp involving the mucosa and submucosa that could resemble an adenoma, a hyperplastic, or a juvenile polyp. Ganglioneuromatous polyposis is characterized by more than 20 sessile or pedunculated mucosal or submucosal lesions that endoscopically resemble familial adenomatous polyposis. Diffuse ganglioneuromatosis is a large poorly-demarcated nodular and disseminated proliferation of ganglioneuromatous tissue [1]. Typically, ganglioneuromatosis are large (up to 17 cm), poorly demarcated, and often infiltrate the adjacent bowel wall and distort the surrounding tissue architecture. Ganglioneuromas can be found anywhere in the body, although involvement of the GI tract is a rare occurrence. Most patients with GNs are asymptomatic and are usually discovered on screening colonoscopies, although rarely may present with gastrointestinal symptoms such as abdominal pain, constipation, weight loss, bleeding, or obstruction depending on the size and location of the polyp. The diagnosis of GN is based on the recognizing ganglion cells with hematoxylin and eosin stain. NSE and S100 protein are essential in confirming and evaluating the extent of the lesion. The differential diagnosis of these lesions includes neurofibromas and schwannomas, both of which lack ganglion cells [2]. GNs have been detected in patients with multiple endocrine neoplasia (MEN) type IIb [3], Cowden syndrome(CS) [4], familial adenomatous polyposis coli [5], tuberous sclerosis [6], and neurofibromatosis type 1 (NF-1) [1, 7]. Current guidelines have no specific recommendations to directly address GNs, especially in the setting of finding solitary polypoid GNs during routine screening. Moreover, GNs have an association with hereditary syndromes and possibly an increased risk of malignancies. In this report, we present a case of solitary colonic ganglioneuroma found during a routine screening colonoscopy with a current literature review with the goal of providing some guidance to gastroenterologists when they encounter this diagnosis.

Two Cases of Paradoxical Hidradenitis Suppurativa while on Adalimumab

Hidradenitis suppurativa (HS) is a chronic, inflammatory skin disease characterized by recurring abscesses, nodules, and fistulas predominantly in the groin and axillae. The association between HS and Crohn’s disease (CD) has been well documented. Tumor necrosis factor (TNF) inhibitors have shown to be effective in treating both HS and CD. We report 2 patients who developed HS while on TNF inhibitor treatment for CD.

Sa1952 Delayed Intramural Duodenal Hematoma: An Unusual Cause of Gastric Outlet Obstruction in an Adult

Introduction: Isolated collagenous gastroduodenitis (CGD) with no colonic involvement is an extremely rare entity with only 2 cases reported in the literature. We report a case of isolated CGD presenting as nausea, vomiting, abdominal pain and profound weight loss. Case: A 63-year-old African American woman presented with two-year history of nausea, vomiting, upper abdominal pain and sixty pounds weight loss. There was no history of diarrhea, gastrointestinal (GI) bleeding or skin changes. Prior evaluation, including esophagogastroduodenoscopy, colonoscopy with biopsies and a video-capsule endoscopy only revealed gastric mucosal edema. Celiac serologies were negative and a gluten free diet failed to improve her symptoms. She was hospitalized for severe malnutrition and total parenteral nutrition (TPN) was started. Laboratory evaluation revealed Hemoglobin of 12.4g/dl, albumin 2.6g/dl, positive antinuclear antigen (1:640), and positive anti SCL-70 antibody. Push enteroscopy showed inflammatory changes in the stomach and the small bowel (SB) wall mucosa appeared edematous and nodular. Biopsies revealed inflammatory changes and thickened collagen table consistent with CGD. She was started on oral prednisone, mycophenolate mofetil (MMF), and high dose proton pump inhibitors. Prednisone was eventually tapered off and the TPN was discontinued. At 4 months, repeat push enteroscopy showed normal looking SB mucosa. Biopsies revealed no collagen table. She has regained her baseline weight and is currently maintained only on MMF. Discussion: Collagenous gastroenteritides are characterized by marked subepithelial collagen deposition with mucosal inflammatory infiltrate. Isolated collagenous gastritis presents with anemia, weight loss, dyspepsia and epigastric pain. Endoscopy shows thickened and nodular mucosa, erosions, and ulcerations. Diagnosis is made by histology, with increased subepithelial collagen band thickness to at least 10 μm and inflammatory cell response with predominant mononuclear infiltrate in the lamina propria. GI involvement in scleroderma can also present similarly, however, endoscopic findings are more consistent with gastric antral vascular ectasia (GAVE) and histology is characterized by mucosal capillary dilatation with fibromuscular hyperplasia. The histological features in our case typify CGD and were not consistent with GI scleroderma. A variety of therapies for CGD have been tried including corticosteroids, Bismuth subsalicylate, Mesalazine, and hypoallergenic diets. Steroids can lead to clinical improvement, however, endoscopic or histological improvement has not been documented. The uniqueness in our case is significant clinical, endoscopic and histologic response to steroid and MMF therapy. With increased awareness and reporting of such cases, diagnostic and management strategies may be better elucidated.