James H. Grendell

The Appendix May Protect Against Clostridium difficile Recurrence

BACKGROUND & AIMS Several risk factors have been identified for the development of recurrent Clostridium difficile infection (CDI) that alter host immunity and disrupt colonic flora. Although the function of the appendix has been debated, its active, gut-associated lymphoid tissue and biofilm production indicate potential roles in recovery from initial CDI and protection against recurrent CDI. We investigated whether the presence or absence of an appendix is associated with CDI recurrence. METHODS We reviewed the medical records of adult inpatients with CDI who were admitted to a tertiary-care teaching hospital from 2005 to 2007 to identify those with and without an appendix. The primary dependent variable for statistical analysis was CDI recurrence. RESULTS In a multivariate analysis of 11 clinical variables, the presence of an appendix was associated inversely with CDI recurrence (P < .0001; adjusted relative risk, .398). Age older than 60 years also was associated with CDI recurrence (P = .0280; adjusted relative risk, 2.44). CONCLUSIONS The presence of an appendix has a significant and independent, inverse association with CDI recurrence, but this finding requires validation in a prospective study. Assessing the presence or absence of an appendix might be useful in predicting CDI recurrence.

High yield of same-session EUS-guided liver biopsy by 19-gauge FNA needle in patients undergoing EUS to exclude biliary obstruction

BACKGROUND EUS-guided liver biopsy by Trucut yields variable specimen adequacy at high cost, limiting its utility. A modified EUS-guided technique with reliable adequacy could be a viable alternative to standard techniques in cost-effective clinical settings. OBJECTIVE To describe our experience with EUS-guided liver biopsy by 19-gauge FNA, non-Trucut, needle in a cost-effective setting: patients with abnormal liver test results of unclear etiology referred for EUS to exclude biliary obstruction in whom an unrevealing EUS would have prompted a next-step liver biopsy by the referring physician. DESIGN Prospective case series. SETTING Tertiary-care teaching hospital. PATIENTS Consecutive patients with abnormal liver tests referred for EUS. INTERVENTIONS EUS-guided liver biopsy by 19-gauge FNA needle (non-Trucut). MAIN OUTCOME MEASUREMENTS Diagnostic yield, specimen adequacy, and complications. An adequate specimen was defined as a length of 15 mm or longer and 6 or more complete portal tracts (CPTs). RESULTS Between July 2008 and July 2011, 22 of 31 consecutive patients meeting inclusion criteria underwent unrevealing EUS with same-session EUS-guided liver biopsy by 19-gauge FNA needle. A median of 2 FNA passes (range 1-3) yielded a median specimen length of 36.9 mm (range 2-184.6 mm) with a median of 9 CPTs (range 1-73 CPTs). EUS-guided liver biopsies yielded a histologic diagnosis and adequate specimens in 20 of 22 patients (91%). Expanded experience led to improved specimen adequacy. There were no complications. LIMITATION Small study size. CONCLUSIONS EUS-guided liver biopsy by using a 19-gauge FNA needle appears to be feasible and safe and provides excellent diagnostic yield and specimen adequacy.

Endoscopic approaches to treatment of achalasia

Endoscopic therapy for achalasia is directed at disrupting or weakening the lower esophageal sphincter (LES). The two most commonly utilized endoscopic interventions are large balloon pneumatic dilation (PD) and botulinum toxin injection (BTI). These interventions have been extensively scrutinized and compared with each other as well as with surgical disruption (myotomy) of the LES. PD is generally more effective in improving dysphagia in achalasia than BTI, with the latter reserved for infirm older people, and PD may approach treatment results attained with myotomy. However, PD may need to be repeated. Small balloon dilation and endoscopic stent placement for achalasia have only been used in select centers. Per oral endoscopic myotomy is a newer endoscopic modality that will likely change the treatment paradigm for achalasia. It arose from the field of natural orifice transluminal endoscopic surgery and represents a scarless endoscopic approach to Heller myotomy. This is a technique that requires extensive training and preparation and thus there should be rigorous accreditation and monitoring of outcomes to ensure safety and efficacy.

Type 2 autoimmune pancreatitis: case report of a 9-year-old female and a review of the literature

We report a case of autoimmune pancreatitis in a 9-year-old female who presented with persistent epigastric pain for 3 weeks. Magnetic resonance cholangiopancreatography (MRCP) showed both intrahepatic and extrahepatic biliary ductal dilatation. The common bile duct, along with the pancreatic duct, was noted to be dilated. Labs showed normal IgG and IgG4 levels and negative for autoimmune antibodies. Endoscopic ultrasound revealed the pancreatic head to be enlarged and surrounded by hypoechoic and lobulated lymph nodes. Biopsy of the pancreatic head showed chronic mildly active inflammation with fibrosis, acinar atrophy, and lymphocytic infiltrate. A diagnosis of autoimmune pancreatitis (AIP) was made, and she was treated with prednisone. The patient’s symptoms improved quickly, and follow-up MRCP showed resolution of inflammatory changes and intrahepatic and pancreatic ductal dilatation.

Acute pancreatitis and pseudocyst due to a closed loop obstruction from an epigastric hernia.

C 62-year-old woman with history of an epigastric hernia presented with worsening abdominal pain over 3 days. She enied any fevers, chills, nausea, vomiting, or change in bowel abits, and had no prior surgical history. On exam, her abdoen was soft with an incarcerated hernia and epigastric tenerness. Laboratory data revealed a white blood cell count of 8.4 K/uL, amylase of 581 U/L, lipase of 700 U/L, and alkaline hosphatase of 144 IU/L. A computed tomography scan of the bdomen (Figure A) showed evidence of a ventral abdominal all hernia containing a dilated distal stomach and head of the ancreas with minimal contrast seen distally. Findings consisent with acute pancreatitis and an 11.8 by 8.4 cm fluid collecion anterior to the body of the pancreas were also noted.

Image of the month: A rare cause of obstructive jaundice in a postpartum woman.

A rare cause of obstructive jaundice in a postpartum woman. A 35-year-old woman was admitted to our emergency department with a 2-week history of fever, abdominal pain, and icterus. She had had a normal vaginal delivery 1 month previously. A clinical diagnosis of cholangitis was considered. Serum biochemistry revealed an obstructive situation with raised alkaline phosphatase (550 IU) and direct bilirubin (5.5 mg/dl). Abdominal ultrasonography showed choledocholithiasis. Cholangiogram during endoscopic retrograde cholangiopancreatography revealed dilatation of the common bile duct with an oval filling defect at the lower end suggestive of a calculus. In addition, there was a linear filling defect oriented along the axis of the common bile duct (left). Following papillotomy, a coiled white shiny structure could be seen just at the ampulla (middle). Extraction revealed it to be a roundworm (right). (Submitted by Pankaj Gupta, Saroj Kant Sinha, Rakesh Kochhar, and Uma Debi, Post-Graduate Institute of Medical Education and Research, Chandigarh, India.)