Jonathan Keshishian

Negative predictive value of positron emission tomography/computed tomography in patients with a clinical suspicion of pancreatic cancer.

Objectives: The aim of this study was to determine the negative predictive value of positron emission tomography (PET)/computed tomography (CT) in patients with lesions suggestive of pancreatic cancer. Methods: A retrospective review from January 2005 to August 2008 of all patients who underwent a PET/CT to evaluate a lesion suggestive of pancreatic cancer based on prior imaging. One hundred eighty-four patients underwent PET/CT, of which 60 patients had a negative PET scan. Of these 60 patients, 56 patients (30 women, 26 men) had endoscopic ultrasound-guided fine-needle aspiration or surgical pathology for clinical correlation. The Fisher exact test was used for statistical analysis. Results: The negative predictive value of PET/CT was 75%. Eighteen patients had a benign lesion, 24 patients had a premalignant lesion, and 14 patients had a malignant lesion. In the cystic group, 72.4% of the PET/CT-negative lesions were premalignant compared with the solid group that was only 5.9%. This was in contrast to the solid group, where 64.7% was malignant versus 6.9% in the cystic group. Two of 14 patients with malignancy had metastatic disease. Conclusions: The negative predictive value of PET/CT in pancreatic lesions suggestive of pancreatic cancer was 75%. A negative PET/CT does not exclude pancreatic cancer, and further workup of these PET-negative lesions is warranted.

The Black Esophagus: A Rare But Deadly Disease

We present a series of cases of acute esophageal necrosis along with a video demonstration. The video captures a case showing the severity of necrosis of the esophageal mucosa; an orogastric tube easily passed through the esophageal lumen and into the right hemithorax. The series also demonstrates the severity of this illness, with an associated high mortality rate.

Eosinophilic esophagitis: a paradigm shift for pathology.

Background: Eosinophilic esophagitis (EoE) is an increasingly recognized disease only reported in the adult literature since 1993. Our facility has the opportunity to evaluate steroid-naive EoE patients since 1988, allowing us to describe the evolution of the histologic diagnosis of EoE. Methods: This retrospective study analyzed 95 patient charts with initial diagnosis of congenital esophageal stenosis/EoE from 1988 to 2012. Patients had dysphagia and met endoscopic criteria consistent with current EoE histologic criteria while on chronic proton-pump inhibitor therapy. Histologic slides were obtained for only 10 patients because of limited slide availability; and the slides were reviewed by a single pathologist. EoE is defined as ≥1 biopsy specimens demonstrating >15 eosinophils/HPF. Results: Following review of histologic analysis reports, pathologists in our 2 academic hospitals began recognizing EoE as separate disease entity starting in 2007, coincidental with first EoE guidelines. After 2007, there was a clear surge in histologic diagnosis of EoE. Slides from 10 patients from 1988 to 2012 were reviewed. Of 35 biopsy sets, 19 were previously interpreted as reflux esophagitis (RE) or acute/chronic inflammation, 3 as RE with eosinophils, 2 as normal, and 11 as EoE. Reevaluation revealed EoE in 79% specimens with RE/inflammation and 100% with RE and eosinophils; remaining specimens had confirmed original diagnosis. All 10 patients had at least one set of slides meeting current EoE histologic criteria. Conclusions: EoE as a disease has been present for at least 2 to 3 decades. This is the first report of a clearly demarcated time point reflecting a paradigm shift in the histologic diagnosis of EoE as a distinct entity resulting from a seminal consensus report.

Biliary Fascioliasis Mimicking Sphincter of Oddi Dysfunction

Fasciola hepatica, a liver fluke of livestock, rarely presents as chronic biliary tract infection in humans. We report a 38-year-old woman from Ethiopia who presented with right upper quadrant pain and a dilated common bile duct on ultrasound and magnetic resonance cholangiopancreatography (MRCP) without other abnormalities. She was suspected to have type II sphincter of Oddi dysfunction. She underwent endoscopic retrograde cholangiopancreatography (ERCP) and had a fluke, diagnosed as Fasciola hepatica, in the common hepatic duct. This report confirms the diagnostic and therapeutic role of ERCP in the management of biliary fascioliasis, and highlights the need to include fascioliasis in the differential diagnosis of biliary pain in patients emigrating from areas where this infection is endemic.

CASE 9—2015 Anesthetic Management of a Patient With Esophago-Pericardial Fistula Complicating Atrial Fibrillation Radiofrequency Ablation

AF is tailored toward rhythm and heart rate control using anti- arrhythmic medications and anticoagulation therapy to prevent embolic stroke. However, antiarrhythmic therapy fails in a significant number of patients. Drug-refractory AF currently is managed with catheter ablation (CA) procedures, which are associated with a complication rate of about 5% and a mortality rate of approximately 0.001%. 3-11 CA procedures, such as cryoablation and radiofrequency ablation (RFA), can be associated with the following early periprocedure complications: bleeding from cardiovascular injury, cardiac tamponade, pericarditis, pulmonary vein (PV) thrombosis, and embolic stroke. Late CA-related complications include esophago-pericardial fistula (EPF), left atrial-esophageal fistula (LAEF), stroke, PV stenosis, and death. 3,4,7,9-13 The mechanism of LAEF and EPF formation is not clear. However, direct thermal injury and ischemia to the esophagus have been described as inciting complications after RFA and cryoablation procedures. These complications typically occur during posterior ablation of the left atrium (LA) and the PVs. Post-thermal injury esophageal inflammation, necrosis, and/or adhesion to the heart

Colonic stasis and chronic constipation: Demystifying proposed risk factors for colon polyp formation in a spinal cord injury veteran population

Background and Aims: Patients with spinal cord injury (SCI) suffer significant morbidity from neurogenic bowel. Chronic constipation has long-been a proposed risk factor for polyp development. We performed a retrospective cohort study in veterans with SCI to assess polyp presence in the setting of colonic stasis. Methods: All consecutive patients at the James A. Haley Veterans Affairs Hospital with SCI and neurogenic bowel who completed screening colonoscopy between January 1, 2004 to June 30, 2013 were included. Colonoscopies were excluded if they were aborted, not completed to the cecum, of less than adequate preparation, or if polypectomy was precluded. Patient data included level, duration, and completeness of SCI. Polyp data included number, location, and histology. Results: 325 patients ultimately met inclusion criteria. Most were male (96%). The average age at screening colonoscopy was 62.8 years. The majority of patients had injury to the cervical spine (41.5%). Colon polyps were detected in 130 patients (40%). Adenomatous change was seen in 95 (73%) of these patients. The adenoma detection rate (ADR) across all patients was 29.2%. Polyp presence and ADR demonstrated no statistically significant correlation with level, degree, or duration of SCI. Only patient age at time of screening colonoscopy had a significant correlation with polyp and adenoma presence (P<0.05). Conclusions: SCI had no statistically significant correlation with polyp or adenoma presence. The ADR in our veteran SCI population with chronic constipation is comparable with that reported in the general population.

Embedded Fishhook in the Gastric Cardia: Novel Removal Utilizing Electrocautery Needle-Knife Dissection

Foreign body ingestions often consist of benign objects that will readily pass through the gastrointestinal tract (GI) without necessitating further intervention. While several retrieval devices and techniques are available to the endoscopist, we present a novel method of implementing a needle-knife sphincterotome in the removal of an ingested fishhook embedded in the gastric cardia of a 36-year-old man with underlying schizophrenia. The hook was successfully dissected from the gastric submucosa after several unsuccessful attempts at manual extraction with forceps. To our knowledge, our case represents one in only a handful of other reports of the successful removal of ingested foreign bodies utilizing this method.

S2025 Negative Predictive Value of PET/CT in a Large Series of Patients with a Clinical Suspicion of Pancreatic Cancer

Introduction: Epidemiologic and experimental studies have shown that dietary intake of n3 polyunsaturated fatty acid (PUFA) reduces cancer risk. We have previously reported that in contrast to the n-6 PUFA arachidonic acid (AA) the n-3 PUFA eicosapentaenoic acid (EPA) decreased pancreatic cancer (PaCa) growth. However, the observed effects using standard two dimensional (2D) culture conditions were only modest. It has become increasingly recognized that the phenotype of cultured cancer cells changes if cells are allowed to grow in more physiologically relevant three-dimensional (3D) assays. The aim of the present study was therefore to assess the effects of AA and EPA on PaCa cell growth using 3D growth assays. Methods and results: The human PaCa cell lines MIA PaCa-2 with (MP2+COX2) or without (MP2-COX2) stable COX-2 expression, and BxPC-3, which express wildtype COX2, were used for our studies. Culture dishes were coated with 50% Matrigel (diluted 1:1 with serum-free culture medium). Cells were seeded on top and overlaid with serum-free culture medium. Fatty acids were present in the Matrigel and the culture medium on top. Colony formation and cell growth were measured after 5-7 days by counting and BrdU incorporation. For comparison, standard 2D growth was evaluated using MTT assays. Exposure of MP2+COX2 cells to AA (5 μM) in the 3D assay increased the growth by more than 10-fold (count) and 2.8-fold (BrdU incorporation), while it enhanced growth only by 1.5fold in the 2D assay (MTT). EPA (200 μM) decreased growth in 3D assays by more than 10-fold but only by 1.6-fold in 2D assays. Similar effects were seen in the COX-2 expressing BxPC-3 cells. In MP2-COX2 cells, AA had only a marginal growth-enhancing effect, which was still more pronounced in 3D assays (2.5-fold increase in cell count vs. 1.3-fold increase in MTT). EPA also markedly decreased cell growth in MP2-COX2 cells with a more than 10-fold reduction in 3D assays but only a 3.6-fold decrease in 2D assays. Conclusion: In pancreatic cancer cells the growth enhancing effects of the n-6 PUFA AA as well as the growth inhibitory effects of the n-3 PUFA EPA were significantly more pronounced in 3D culture assays compared to standard 2D assays. AA significantly increased the growth of COX-2 positive pancreatic cancer cells, while EPA decreased the growth of COX-2 positive and -negative pancreatic cancer cells. This suggests that the effects of EPA on pancreatic cancer cell growth are at least in part mediated by COX-2 independent mechanisms. Our data suggest that the physiologically more relevant 3D culture system should be the preferred model to evaluate drug efficiency In Vitro.