Gulshan Parasher

Conservative management of cholelithiasis and its complications in pregnancy is associated with recurrent symptoms and more emergency department visits

BACKGROUND Pancreaticobiliary complications of gallstones are common in pregnancy and can result in serious sequelae. Previous studies have shown conflicting results regarding different approaches of treatment. OBJECTIVE To compare the outcomes of conservative treatment versus operative and endoscopic interventions in the management of complications related to gallstones during pregnancy. DESIGN Retrospective chart review. SETTING Tertiary-care referral facility. PATIENTS A total of 112 patients who had complications related to gallstones during pregnancy. INTERVENTION Patients were classified into 3 groups: conservative treatment, laparoscopic cholecystectomy (LC), and ERCP. MAIN OUTCOME MEASUREMENTS We collected demographic data and information regarding treatment complications and pregnancy outcomes. RESULTS A total of 112 pregnant patients met the inclusion criteria, with a mean age of 25 years. Main clinical presentations were biliary colic (n = 56), biliary pancreatitis (n = 27), acute cholecystitis (n = 17), and choledocholithiasis (n = 12). A total of 68 patients underwent conservative treatment, 13 patients underwent ERCP, 27 patients had LC, and 4 patients received both ERCP and LC. Recurrent biliary symptoms were significantly more common in patients who received conservative treatment (P = .0005). The number of emergency department visits was significantly higher in the conservative treatment group compared with the active intervention group (P = .0006). The number of hospitalizations also was higher in the conservative treatment group (P = .03). Fetal birth weight was similar in both groups (P = .1). Patients treated conservatively were more likely to undergo cesarean section operations for childbirth (P = .04). LIMITATIONS Single-center, retrospective study. CONCLUSION Conservative treatment of cholelithiasis and its complications during pregnancy is associated with recurrent biliary symptoms and frequent emergency department visits. ERCP and LC are safe alternative approaches during pregnancy.

Mesothelin and GPR30 Staining Among a Spectrum of Pancreatic Epithelial Neoplasms

Introduction: Our study attempts to characterize mesothelin and GPR30 / estrogen receptor (ER) staining in pancreatic pathology. Materials and Methods: Immunohistochemical staining for mesothelin, GPR30, and ER was performed on a variety of pancreatic lesions. Results: 24 of 42 (57%) adenocarcinomas stained for mesothelin, while 0 of 16 non-carcinomas (0%) stained (p = 0.0000784). 35 of 39 (90%) adenocarcinomas stained for GPR30, while only 4 of 15 (27%) non-carcinomas stained (p = 0.0000036). Apart from stromal staining in one case of mucinous cystic neoplasm, no cases stained for ER. 27 of 37 (73%) adenocarcinoma fine needle aspirates were positive for mesothelin. Discussion: GPR30 is more sensitive, but less specific than mesothelin for pancreatic adenocarcinoma. Mesothelin is detected in most adenocarcinoma fine needle aspirates. ER is rarely detected in pancreatic lesions.

Extra-Pancreatic Pancreatitis: A Rare Cause of Abdominal Pain

During fetal development, pancreatic tissue on rare occasions is implanted ectopically. This ectopic pancreas, or pancreatic heterotopia, arises during the embryological phase of foregut rotation, when fragments of pancreas separate from the main body, implanting most commonly in the gastrointestinal tract, where they are termed pancreatic rests or heterotopia. We describe a woman with chronic pancreatitis and a pseudocyst arising in a gastric pancreatic rest producing abdominal pain and vomiting that resolved after surgical resection.

A 50-Year-Old Man with Postprandial Epigastric Pain

A 50-year-old otherwise healthy man, with moderate hypertension, had suffered from intermittent postprandial epigastric pain and bloating for over 3 years. The pain was moderate in intensity, lasted for about 1 h, did not radiate, and had no obvious other precipitating or relieving factors. Although occasional belching was noted, the pain was not accompanied by nausea, vomiting, weight loss, or disturbance of bowel habits. Physical examination revealed an obese man with normal vital signs. His abdomen was soft, non-tender, and non-distended, and bowel sounds were normal. There were no masses palpable in the abdomen. Results of routine blood tests, including serum liver enzymes, bilirubin, amylase, and lipase, carcinoembryonic antigen and CA19-9, were all normal. Solid gastric emptying, delayed 36 % at 2 h, was initially treated empirically with domperidone 10 mg postoperatively three times a day, with partial relief of symptoms. A 0.5-cm duodenal bulb carcinoid was removed via endoscopic mucosal resection, with considerable improvement in his symptoms. Nevertheless, 2 years later during routine follow-up, an elevated serum concentration of chromogranin A, without elevation of concentration of any other gut hormone, was noted as part of an investigation for symptomatic relapse. A computerized tomographic (CT) scan of his abdomen and pelvis was unremarkable. He was then referred to an endoscopic ultrasound examination to evaluate the possibility of having residual or recurrent carcinoid tumor. Radial endosonography (EUS), although revealing no evidence of residual tumor, identified circumferential pancreatic tissue around the second portion of the duodenum, immediately distal to the duodenal sweep, with associated luminal narrowing (Figs. 1, 2). A magnetic resonance imaging (MRI) scan, with MR cholangiopancreatography (MRCP), confirmed the existence of an annular pancreas (Fig. 3a, b). A subsequent upper gastrointestinal barium study displayed narrowing of the second portion of the duodenum, but failed to reveal the presence of a dilated duodenal bulb, characteristic of the condition.

Chronic Abdominal Pain, Ascites, and Diarrhea: Seeing Red

A 38-year-old male patient, otherwise healthy except for a five year medical history of diet-controlled diabetes mellitus, was initially evaluated in the emergency department with complaints of abdominal pain and diarrhea of 2 months duration. The pain, described as sharp, moderately severe, and intermittent, was located in the right upper and lower quadrants, did not radiate, and lasted only for a few minutes at a time. Multiple episodes of the pain occurred throughout the day, with no obvious precipitating or relieving factors. He also described having had, over the same period, watery diarrhea, 8 to 10 times a day, with no blood or mucus in the stool. The patient denied having had any nausea, vomiting, fever, chills, night sweats, or weight loss. Helicobacter pylori infection, diagnosed by serum antibodies, was treated with pantoprazole, clarithromycin, and amoxicillin for 2 weeks without changes in the abdominal pain pattern or character. Physical examination revealed an overweight patient with normal vital signs. The abdomen was distended with dullness to percussion noted in the flanks with periumbilical resonance and a positively transmitted fluid wave. Bowel sounds were present; there was no tenderness to palpation or overlying skin changes. Jugular venous pressure was not elevated, and ankle edema was absent. Stigmata of chronic liver disease were not apparent. There was no enlargement of the liver, spleen, or regional lymph glands and no additional palpable masses.

C-kit-positive gastric metastasis of lobular carcinoma of the breast masquerading as gastrointestinal stromal tumor

A 61-year-old woman with no significant past history underwent gastric biopsies demonstrating a strongly c-kit-positive epithelioid malignancy, initially thought to represent gastrointestinal stromal tumor (GIST). Subsequent clinical and immunohistochemical evaluation proved the neoplasm to represent metastatic lobular carcinoma. This case illustrates that although c-kit is highly specific and sensitive for GIST, its expression may occur in a variety of other neoplasms, some of which morphologically resemble GIST and may present in the gastrointestinal tract as metastases. Therefore, a review of other c-kit-positive lesions is also highlighted.

A multicenter evaluation of a new EUS core biopsy needle: Experience in 200 patients

Background and Objectives: We present a multicenter study of a new endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) needle (Acquire, Boston Scientific, Natick, MA). The aim of the study was to analyze the needles clinical performance when sampling solid lesions and to assess the safety of this device. Methods: We performed a multicenter retrospective study of patients undergoing EUS-FNB during July 1–November 15, 2016. Results: Two hundred patients (121 males and 79 females) underwent EUS-FNB of solid lesions with the Acquire needle. Lesions included solid pancreatic masses (n = 109), adenopathy (n = 45), submucosal lesions (n = 34), cholangiocarcinoma (n = 8), liver lesions (n = 6), and other (n = 8). Mean lesion size was 30.6 mm (range: 3–100 mm). The mean number of passes per target lesion was 3 (range: 1–7). Rapid onsite cytologic evaluation (ROSE) by a cytologist was performed in all cases. Tissue obtained by EUS-FNB was adequate for evaluation and diagnosis by ROSE in 197/200 cases (98.5%). Data regarding the presence or absence of a core of tissue obtained after EUS-FNB were available in 145/200 procedures. In 131/145 (90%) of cases, a core of tissue was obtained. Thirteen out of 200 patients (6.5%) underwent some form of repeat EUS-based tissue acquisition after EUS-FNB with the Acquire needle. There were no adverse events. Conclusion: Overall, this study showed a high rate of tissue adequacy and production of a tissue core with this device with no adverse events seen in 200 patients. Comparative studies of different FNB needles are warranted in the future to help identify which needle type and size is ideal in different clinical settings.

An endoscopic end to coma

ABSTRACT A 23-year-old man presented to the emergency department after ingesting an unknown amount of an immediate-release preparation of carbamazepine. Thirty minutes after presentation, he became obtunded and required intubation for airway protection. Initial serum carbamazepine concentration was 59 μg/mL and peaked at 120 μg/mL 16 hours later. High-flux hemodialysis (HFHD) was performed, followed by continuous venovenous hemodiafiltration (CVVH). The patient remained comatose as his hospital course was remarkable for prolonged serum carbamazepine toxicity. On day 12, esophagogastroduodenoscopy (EGD) was performed and a 5 cm carbamazepine bezoar weighing 9.9 g was recovered from his stomach using an esophageal overtube and a Roth Net to facilitate extraction. Following endoscopic intervention, serum carbamazepine concentrations rapidly declined and his mental status improved with no permanent neurological deficit or other sequelae.

Evaluation and Management of Mucosal and Submucosal Lesions in the Foregut

Submucosal or, more appropriately, subepithelial lesions are occasionally seen during upper gastrointestinal endoscopy. A minority turn out to be structures outside the gut wall but most are true intramural lesions. A majority of these lesions are found incidentally and are asymptomatic. Examples of these lesions include malignant or potentially malignant tumors such as gastrointestinal stromal tumors (GISTs) and carcinoids as well as benign lesions (lipoma, duplication cyst, heterotopic pancreas). Diagnosis often cannot be made by endoscopy alone. Endoscopic ultrasound helps narrow the differential diagnosis of a subepithelial lesion based on echogenicity and layer of origin. It also allows for deeper tissue acquisition and evaluation for candidacy for endoscopic resection. Management including endoscopic resection, surgical resection, or surveillance depends on the presence of symptoms, size, and histology if obtained.

Oesophageal stent placement to treat a massive iatrogenic duodenal defect after laparoscopic cholecystectomy

Iatrogenic duodenal injury occurring during laparoscopic cholecystectomy (LC) is managed surgically, though rarely a large, persistent fistula is refractory to surgical interventions. We present the case of a 40-year-old woman transferred to our centre following elective LC for a reported perforated duodenal ulcer. An uncontained leak was found to originate from a 1.5 cm duodenal defect, with no evidence of ulceration. A duodenostomy tube was placed. One month after abdominal closure, the patient continued to have a persistent, large duodenal fistula. A through-the-scope covered oesophageal stent was placed under endoscopic and fluoroscopic guidance. Five weeks later, it was successfully retrieved and no subsequent extravasation of contrast from the duodenum was noted. Unrecognised iatrogenic duodenal injuries sustained during LC can be catastrophic. In cases of massive duodenal defects and high-output biliary fistula uncontrolled after surgical intervention, endoscopic-guided and fluoroscopic-guided placement of a fully covered oesophageal stent may be lifesaving.