Hsu-Heng Yen

Clinical challenges and images in GI

Gastroenterology 2015;148:298–299 Question: A 78-yearold man presented to our gastroenterologist outpatient clinic with anal foreign body sensation and tenesmus for half a year. He had a past history of hypertension and peptic ulcer disease. He denied weight loss, bloodtinged stool, or abdominal pain. Physical examination was not remarkable. Rectal digital examination found an elastic nodular lesion at 3 cm above the anal verge. Laboratory studies including hemoglobin, liver enzymes, renal function, and tumor markers (carcinoembryonic antigen and cancer antigen-125) were all within normal range. Colonoscopy showed a 25-mm polypoid, elastic lesion with smooth mucosa and a stalk (0-Ip) on the dentate line (Figure A). Image enhanced endoscopy with narrow band image disclosed normal pit pattern and vasculature (Figure B). In concerning with related symptoms from the lesion, polypectomy was performed. Correlating his clinical and images findings, what is your diagnosis? Look on page 299 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Decreased mitochondrial deoxyribonucleic acid and increased oxidative damage in chronic hepatitis C

AIM To determine whether alteration of the mitochondria DNA (mtDNA) copy number and its oxidative damage index (mtDNA(∆CT)) can be detected by analysis of peripheral blood cells in hepatitis C virus (HCV)-infected patients. METHODS This study enrolled two groups of patients aged 40-60 years: a control group and an HCV-infected group in Department of Gastroenterology and Hepatology in Changhua Christian Hospital. Patients with co-infection with hepatitis B virus or human immunodeficiency virus, autoimmune disease, malignant neoplasia, pregnancy, thyroid disease, or alcohol consumption > 40 g/d were excluded. HCV-infected patients who met the following criteria were included: (1) positive HCV antibodies for > 6 mo; (2) alanine aminotransferase (ALT) levels more than twice the upper limit of normal on at least two occasions during the past 6 mo; and (3) histological fibrosis stage higher than F1. The mtDNA copy number and oxidative damage index of HCV mtDNA (mtDNA(∆CT)) were measured in peripheral blood leukocytes. The association between mtDNA copy number and mtDNA(∆CT) was further analyzed using clinical data. RESULTS Forty-seven normal controls (male/female: 26/21, mean age 50.51 ± 6.15 years) and 132 HCV-infected patients (male/female: 76/61, mean age 51.65 ± 5.50 years) were included in the study. The genotypes of HCV-infected patients include type 1a (n = 3), type 1b (n = 83), type 2a (n = 32), and type 2b (n = 14). Liver fibrosis stages were distributed as follows: F1/F2/F3/F4 = 1/61/45/25 and activity scores were A0/A1/A2/A3 = 7/45/55/25. There were no age or gender differences between the two groups. HCV-infected patients had higher hepatitis activity (aspartate transaminase levels 108.77 ± 60.73 vs 23.19 ± 5.47, P < 0.01; ALT levels 168.69 ± 93.12 vs 23.15 ± 9.45, P < 0.01) and lower platelet count (170.40 ± 58.00 vs 251.24 ± 63.42, P < 0.01) than controls. The mtDNA copy number was lower in HCV-infected patients than in controls (173.49 vs 247.93, P < 0.05). The mtDNA(∆CT) was higher in HCV-infected patients than in controls (2.92 vs 0.64, P < 0.05). To clarify the clinical significance of these results in HCV-infected patients, their association with different clinical parameters among HCV-infected patients was analyzed. A negative association was found between mtDNA copy number and elevated aspartate transaminase levels (r = -0.17, P < 0.05). Changes in mtDNA copy number were not associated with HCV RNA levels, HCV genotypes, liver fibrosis severity, or inflammatory activity in the liver biopsy specimen. However, a correlation was observed between mtDNA(∆CT) and platelet count (r = -0.22, P < 0.01), HCV RNA level (r = 0.36, P < 0.01), and hepatitis activity (r = 0.20, P = 0.02). However, no difference in the change in mtDNA(∆CT) was observed between different fibrosis stages or HCV genotypes. CONCLUSION Oxidative stress and mtDNA damage are detectable in patients peripheral leukocytes. Increased leukocyte mtDNA(∆CT) correlates with higher HCV viremia, increased hepatitis activity, and lower platelet count.

Hemoclip-Assisted Polypectomy of Large Duodenal Brunner's Gland Hamartoma

Brunners gland hamartoma, also known as Brunneroma or Brunners gland adenoma, is a rare tumor of the duodenum and an uncommon cause of gastrointestinal bleeding. In symptomatic patients, treatment requires either surgical resection or endoscopic polypectomy. We report a case of upper gastrointestinal bleeding from a pedunculated Brunners gland hamartoma in the duodenal bulb. A new technique using hemoclip-assisted polypectomy is described to remove a large pedunculated Brunners gland hamartoma.

Esophageal intramural hematoma: an unusual complication of endoscopic biopsy.

Esophageal intramural hematoma (EIH) is a rare form of esophageal injury, whichmay be an intermediate ofMalloryWeiss syndrome (mucosal tear) or Boerhaave’s syndrome (transmural rupture). Patientsusuallypresentwith a sudden onset of retrosternal chest pain, back pain, hematemesis, dysphagia, or odynophagia. The disorder can occur spontaneously, or it can be secondary to variceal injection therapy, esophageal dilatation, food impaction, improper swallowing of drug pills, or coagulopathy. We presently report a novel case of EIH caused by endoscopic biopsy and its successful management by endoscopic therapy.

Successful Double Balloon Enteroscopy Treatment for Bleeding Jejunal Diverticulum: A Case Report and Review of the Literature

In this article, we report a case study of a 54-year old man who presented with massive gastrointestinal bleeding. Esophagogastroduodenoscopy and colonoscopy had been performed in another hospital, but the location of the bleeding could not be identified, and the patient was transferred to our hospital. An initial abdominal computed tomography scan showed only a large blood clot in the small bowel and colon, with duodenojejunal diverticulosis. Emergent angiography was performed due to persistent active bleeding. Active bleeding from the jejunum was found, and the patient received a double balloon enteroscopy, which disclosed active bleeding in one of the jejunal diverticula. Two hemoclips were applied to treat the Dieulafoys lesion within the diverticulum. The patient had no bleeding during the month following treatment. Bleeding of the jejunal diverticulum is a rare clinical condition, and only a few cases have been reported in the literature with successful endoscopic treatment. A short review of the current methods of diagnosis and treatment of this rare disorder is provided.

Spoke-wheel sign of focal nodular hyperplasia revealed by superb micro-vascular ultrasound imaging

A 40-year-old man came to the hospital for follow-up of right hepatic tumor known for 3 years. His medical history is unremarkable. He received physical check-up 3 years ago and a 3.8 cm isoechoic hepatic tumor was found during the ultrasound examination. The previous abdominal computed tomography revealed a well-defined tumor with central scarring tumor in the right liver (Figure 1a). The tumor showed hyperdensity during heptic arterial phase and isodensity during delayed …

Clinical impact of multidetector computed tomography before double-balloon enteroscopy for obscure gastrointestinal bleeding

AIM To evaluate the clinical impact of multidetector computed tomography (MDCT) before double-balloon endoscopy (DBE) for patients with obscure gastrointestinal bleeding (OGIB). METHODS A retrospective analysis of prospectively collected cases with DBE and MDCT for overt OGIB was conducted from April 2004 to April 2010 at Changhua Christian Hospital. We evaluated the clinical impact of MDCT on the subsequent DBE examinations and the diagnostic yields of both MDCT and DBE respectively. RESULTS From April 2004 to April 2010, a total of 75 patients underwent DBE for overt OGIB. Thirty one cases received MDCT followed by DBE for OGIB. The overall diagnostic yields of DBE and MDCT was 93.5% and 45.2%. The MDCT had a high diagnostic yield of tumor vs non-tumor etiology of OGIB (85.7% vs 33.3%, P = 0.014). Additionally, the choice of initial route of DBE was correct in those with a positive MDCT vs negative MDCT (100% vs 52.9%, P = 0.003). CONCLUSION This study suggests MDCT as a triage tool may identify patients who will benefit from DBE and aid the endoscopist in choosing the most efficient route.

Double-balloon enteroscopic treatment for bleeding jejunal diverticulum

The great impersonators of the classic age of medicine were syphilis and tuberculosis, to which renal cell carcinoma, lymphoma, and systemic lupus erythematosus were added later. With the advent of AIDS, Cytomegalovirus (Greek: cyto, cell; megalo, large) became another important impersonator. Think CMV today whenever you see ulcers, polypoid lesions, strictures, and what appears to be ‘‘itis,’’ be it esophagitis, gastritis, enteritis, colitis, pancreatitis, cholecystitis, or even hepatitis. As for why this elderly man has CMV, it is likely the virus was reactivated because of the immunosuppression caused by the prednisone, perhaps in combination with his advancing age. HIV is another possibility, not always tested for; never make judgments, rather do the test and make the diagnosis. And when obtaining biopsy specimens of an ulcer, remember that the more specimens that are taken, with 6 being the minimum, the greater the chance of diagnosing CMVdand take them from the edge of the ulcer as well as the center; CMV likes vascular endothelium, mucosal epithelium, and connective tissue stromal cells. The intranuclear inclusion body giving the appearance of an owl’s eye is an insensitive but highly specific finding for CMV. Owls’ eyes have an abundance of rods and therefore are capable of remarkable black and white vision. When looking for owl eyes in histologic sections, we should also emulate their behavior to look forward and see clearly, but at the same time remember that most of life’s situations are not black and white, but rather shades of gray. Things may not be what they appear to be at first glance. Lawrence J. Brandt, MD Associate Editor for Focal Points At the Focal Point

Fulminant Budd-Chiari syndrome caused by renal cell carcinoma with hepatic vein invasion : report of a case

Budd-Chiari syndrome is a clinical disorder caused by hepatic venous obstruction with manifestations of abdominal pain, hepatomegaly, and ascites. Secondary Budd-Chiari syndrome is defined as an obstruction that results from material not originating from the venous system. We describe a rare case of fulminant Budd-Chiari syndrome secondary to renal cell carcinoma with tumor thrombus of the inferior vena cava and hepatic veins. The 59-year-old man was admitted to our hospital because of progressive appetite loss and markedly elevated serum transaminase. Abdominal ultrasonography revealed thrombosis in the hepatic veins and the inferior vena cava. Renal cell carcinoma with hepatic vein invasion was suggested by abdominal computed tomography and confirmed after a biopsy was taken from the hepatic venous thrombus. The patient died of fulminant liver failure within 10 days after admission. The clinical scenario and rationale for the selected management are further discussed.

Delayed fatal hemorrhage after endoscopic band ligation for gastric Dieulafoy's lesion

Dieulafoy’s lesions are well-known, rare, and diagnostically challenging clinical entities that usually cause massive GI bleeding. We describe a patient who received endoscopic band ligation (EBL) for a bleeding Dieulafoy’s lesion at the gastric cardia. Despite endoscopic follow-up, the patient died from recurrent fatal hemorrhage. To our knowledge, this is the first reported death caused by delayed hemorrhage after EBL for a Dieulafoy’s lesion.