John M. Levey

MIXED CRYOGLOBULINEMIA IN CHRONIC HEPATITIS C INFECTION : A CLINICOPATHOLOGIC ANALYSIS OF 10 CASES AND REVIEW OF RECENT LITERATURE

We present 10 cases of mixed cryoglobulinemia in patients infected with hepatitis C, including pertinent clinical, serologic, and pathological data. The findings attributable to MC appear to be similar in patients who are HCV-infected as in those with unknown HCV status. The prevalence of MC in HCV-infected patients appears to be lower in our region (13%) than in southern Europe (50-90%) although some of this difference is due to our requirement that patients included in our study have a cryocrit of at least 5%. In our patients, cryoglobulins were shown to be deposited in skin and kidney, but not in liver. The mechanisms by which HCV and MC are related remain uncertain. Although we and others have evidence for enrichment of HCV RNA in the cryoprecipitates of some patients, this was not always the case, and it is not yet clear that this finding is of fundamental pathogenic importance. Finally, it appears that some patients with HCV and MC may have a beneficial clinical response of vasculitic symptoms to therapy with alpha-interferon, as well as to glucocorticoids or other immunosuppressants. In our group, no predictors were apparent to distinguish responders from nonresponders before treatment. Similarly, the duration of response remains to be determined.

Extrahepatic manifestations of infection with hepatitis C virus.

Chronic hepatitis C is associated with, and may trigger or exacerbate, an extraordinary variety of extrahepatic manifestations. Most of these manifestations affect the skin, the most frequent and important of which are the leukocytoclastic vasculitis of MC type II and PCT. The former is an example of an autoimmune disorder triggered by HCV infection, whereas PCT is a skin disease caused by hepatic overproduction of uro- and 7-carboxyl porphyrins caused by increased oxidative stress in hepatocytes. Currently available effective therapies of CHC (IFN, ribavirin) may also trigger or exacerbate extrahepatic manifestations, especially including autoimmune thyroiditis, skin rashes, and hemolytic anemia.

Intestinal perforation in a parastomal hernia by a migrated plastic biliary stent

Organ perforation is a well-described complication of plastic biliary stent placement [1-10]. Most commonly, a stent will cause duodenal perforation while still in the area of the biliary system. This often occurs in the setting of a periampullary diverticulum. Less frequently, a perforation occurs as a result of stent migration into the distal lumenal gastrointestinal tract. These cases have involved a migrated stent impacting at the level of the ileum or a sigmoid colon diverticulum. A plastic biliary stent causing perforation inside an

Does trainee participation during colonoscopy affect adenoma detection rates

INTRODUCTION: Training future endoscopists is essential to meeting the increasing demands for colonoscopy. It remains unknown whether adenoma detection rates are adversely affected by trainee participation. METHODS: This is a single-center, prospective study. The primary aim of this study was to investigate whether adenoma detection rates differed between procedures with or without trainee involvement. A total of 368 consecutive patients entered the analysis (181 with trainee participation and 187 without). RESULTS: Adenomas were detected in 19.3% of experienced physician-only procedures and in 14.9% of procedures with trainee participation. Advanced adenomas were detected in 8.6% of experienced physicians’ procedures vs. 4.9% of trainee procedures. Polyp detection was nearly identical in both groups (32% for experienced physicians; 33% for trainees). Trainee participation delayed the procedure by a mean of seven minutes. CONCLUSION: Adenoma detection rates did not differ significantly, whether there was trainee involvement or not. A trend toward finding more adenomas or advanced adenomas in the absence of a trainee was observed, but it was lower than previously reported interobserver variability among experienced physicians. The small difference in adenoma detection was not observed for polyp detection, which may be explained by the more frequent removal of hyperplastic polyps by trainees.

Pyoderma gangrenosum in a patient with collagenous colitis

The association between pyoderma gangrenosum and inflammatory bowel disease is well established. Collagenous colitis is one of the microscopic colitides, which are thought to be on the same spectrum of disease as Crohns disease and ulcerative colitis. Before this study there had been no reported cases of pyoderma gangrenosum in the setting of collagenous colitis. We report a case of a 79-year-old woman with symptomatic collagenous colitis and refractory pyoderma gangrenosum.

Jejunal schwannoma in neurofibromatosis: an unusual cause of massive gastrointestinal bleeding

Small intestinal schwannomas are exceedingly rare tumors arising mainly from Schwann cells of Auerbachs plexus, and are usually solitary and asymptomatic. We report the first case of a jejunal schwannoma causing life-threatening gastrointestinal bleeding in a patient with neurofibromatosis.

Tu1447 A Long Term Retrospective Analysis of Large Polypectomies Using Standard Injection and Lift Techniques

characteristics, lesion location and histology. Statistical analyses were performed using SPSS 19 (SPSS Inc., Chicago, IL, USA). Results: EMR was performed in 1109 lesions 20mm (910 colon, 82%; 199 rectum, 18%). 37 patients did not have EMR and were excluded from analysis (22 cancer suspected; 15 technical difficulties). Significant differences exist in key patient and lesion characteristics, and procedural success rates (Table 1). Rectal lesions had a significantly higher risk of CRC than colonic lesions (11.5% v 6.0%, P 0.007). The odds of CRC in the rectum was 1.6 times greater than in the colon on multiple logistic regression analysis, however was not an independent predictor of CRC (95% CI 0.9-3.0, P 0.138). Independent predictors of CRC were Paris classification and morphology, presence of Kudo pit pattern 5 and lesion size (all P 0.05). The most common subgroup (0-IIa/b G lesions) had the same low risk for CRC in the colon and rectum (2.3% v 2.4%, P 1.000) (Table 2). A Is component in a G lesion magnified the risk of CRC in the colon, which was further increased in the rectum (5.9% v 9.6%, RR 1.63, P 0.196). The same applied to 0-IIa/b lesions with NG morphology in the colon compared to the rectum (7.7% v 22.2%, RR 2.87, P 0.171). NG lesions with a Is component in the rectum had the highest relative risk of CRC (7.1% v 30.8%, P 0.017, RR 4.31, 95% CI for RR 1.2-15.0). Conclusion: Specific subtypes of rectal AMNs have a greater relative risk of CRC compared to colonic AMNs, particularly NG lesions with a Is component. Endoscopic morphology determines the endoscopic therapeutic approach. Independent of site, granular flat lesions can be removed by multi-piece excision, as the risk of CRC is low. However, lesions with a Is component and NG morphology need to be assessed on a case by case basis to determine the correct strategy and should be considered for en bloc resection, particularly when found in the rectum.

Fatal aspergillosis: an unusual complication of steroid therapy for inflammatory bowel disease

Fatal aspergillosis: an unusual complication of steroid therapy for inflammatory bowel disease