Jorge Obando

Iron and HFE or TfR1 mutations as comorbid factors for development and progression of chronic hepatitis C

BACKGROUND/AIMS Recent evidence implicates iron as a comorbid factor for development of non-hemochromatotic liver diseases. Mutations or polymorphisms in the HFE gene or the TfR1 gene may influence the accumulation of iron in the liver or other tissues or may influence chronic viral hepatitis apart from effects on iron homeostasis. The aim of this study was to assess the role of hepatic iron, HFE and TfR1 variations on development and progression of chronic hepatitis C infection. METHODS We studied 119 consecutive patients with chronic hepatitis C, correlating clinical, laboratory, histopathological, and genetic data. Frequencies of genetic variations were compared with local and national controls. RESULTS HFE mutations were more common in patients than controls (48% vs. 38%, P=0.04), and advanced degrees of fibrosis developed at younger ages in subjects with the C282Y mutation (38.6 vs. 46.5 years, P=0.03). Patients carrying C282Y had higher mean hepatic iron concentrations (P=0.02), hepatic iron indices (P<=0.0001), and hepatic fibrosis scores (P=0.01). Hepatic fibrosis was correlated with hepatic iron concentration (P=0.03). TfR1 polymorphisms bore no detectable relation to disease severity or response to therapy. CONCLUSIONS Hepatic iron and HFE mutations are comorbid factors that increase development and progression of chronic hepatitis C.

Pancreatic adenocarcinoma, version 2.2017: Clinical practice guidelines in Oncology

Ductal adenocarcinoma and its variants account for most pancreatic malignancies. High-quality multiphase imaging can help to preoperatively distinguish between patients eligible for resection with curative intent and those with unresectable disease. Systemic therapy is used in the neoadjuvant or adjuvant pancreatic cancer setting, as well as in the management of locally advanced unresectable and metastatic disease. Clinical trials are critical for making progress in treatment of pancreatic cancer. The NCCN Guidelines for Pancreatic Adenocarcinoma focus on diagnosis and treatment with systemic therapy, radiation therapy, and surgical resection.

Review and Recent Development of Angle-Resolved Low-Coherence Interferometry for Detection of Precancerous Cells in Human Esophageal Epithelium

The combination of low-coherence interferometry with angle-resolved light scattering measurements has been shown to be a powerful method for determining the structure of cell nuclei within intact tissue samples. The nuclear morphology data have been used as a biomarker of neoplastic change in a wide range of settings. Here, we review the development of angle-resolved low-coherence interferometry (a/LCI) for assessing the health status of human esophageal epithelial tissues based on depth-resolved measurements of the morphology of cell nuclei. The design and implementation of clinical instrumentation are reviewed, and results from ex vivo human tissue measurements are presented to validate the capabilities of the technique. In addition to the review of earlier papers, new results are presented, which demonstrate the first application of a portable a/LCI system with a flexible endoscopic probe to assessing depth-resolved nuclear morphology in a clinical setting. High sensitivity for the detection of precancerous tissues is demonstrated.

Groove Pancreatitis: Four Cases from a Single Center and Brief Review of the Literature.

Groove pancreatitis is a rare form of chronic pancreatitis that affects the groove anatomical area between the head of the pancreas, duodenum, and common bile duct. We provide a summary of the clinical findings of 4 groove pancreatitis cases diagnosed at a tertiary academic medical center over a 5-year period. A detailed review of the current literature surrounding this clinical entity is also provided. Although rare, groove pancreatitis should be considered in the differential diagnosis of patients presenting with pancreatic head mass lesions, as appropriate diagnosis can help avoid unnecessary surgical procedures.

Pancreatitis Secondary to Celiac Trunk Dissection

Dissection of the visceral arteries happens infrequently, with the superior mesenteric artery being the most commonly affected. Isolated dissection of the celiac trunk is rare, and only a few cases have been reported in the medical literature. We report the case of a 51-year-old male who presented with abdominal pain and was subsequently diagnosed with a celiac trunk dissection with secondary pancreatitis and pancreatic infarction. The patients symptoms improved with conservative medical management. We review the current literature involving celiac trunk dissection and its management, and provide discussion regarding this unrecognized complication of pancreatitis.

Endoscopic Management of Peri-Pancreatic Collections

Endotherapy of peripancreatic fluid collections is an increasing utilized procedure in interventional endoscopy. The aim of this paper is to provide a general overview of the topic, highlighting the indications, technique, and important management issues relating to endoscopic management of the various forms of peri-pancreatic fluid collections.

Does ampullary adenoma size predict invasion on EUS? Does invasion on EUS predict presence of malignancy?

Background and study aims: It is common practice to perform ampullectomy without endoscopic ultrasound (EUS) for ampullary lesions < 1 cm but no data exists to support it. No studies have explored whether EUS findings of invasion correlate with malignancy or high-grade dysplasia (HGD) on pathology. We explored the association between adenoma size, pathology results, and invasion on EUS.  Patients and methods: This was a single-center retrospective cohort study at a large tertiary care academic hospital. Chart review was performed for 161 patients with benign ampullary lesions on endoscopic biopsy (identified by pathology records). The primary outcomes were mean size (mm) of adenomas and pathology findings with and without intraductal and/or duodenal wall invasion on EUS.  Results: Invasion was identified by EUS in 41 (34.1 %) of 120 patients who underwent EUS. The mean size of the lesion in these patients was 20.9 mm (± 11.6 mm) compared to 13.9 mm (± 11.3 mm, P = 0.0001) in patients without invasion. A receiver operating characteristic (ROC) curve (AUC 0.73, 95 % CI 0.63 – 0.83) revealed 100 % sensitivity for absence of invasion on EUS in lesions less than 6.5 mm. Invasion on EUS had sensitivity of 63.0 % (95 % CI 47.0 % – 77.0 %) and specificity 88.0 % (95 % CI 78.0 % – 95.0 %) for presence of malignancy, HGD or invasion on pathology. Conclusions: EUS should be considered for ampullary lesions > 6.5 mm. This study provides evidence to support the practice of ampullectomy without EUS for smaller adenomas. EUS evidence of invasion is highly specific for pathologic malignancy, HGD, or invasion (which preclude endoscopic ampullectomy).

Sa1378 Repeat Endoscopic Ultrasound-Guided Fine Needle Aspiration in Patients With Suspected Pancreatic Neoplasm

G A A b st ra ct s mass prompting biopsy, were excluded. MRI scans performed in patients without a diagnosis of pancreatic cancer served as controls. We used a ratio of 1 control patient for every 3 cancer patients.MRI scans were reviewed in a blinded fashion by two experienced radiologists. A descriptive analysis was performed of MRI findings at 2-24 months prior to the diagnosis of cancer. Agreement between reviewers was assessed via McNemars test and a kappa statistic. Differences between cancer and control group were assessed using chi square tests or fisher exact tests. Results: 550 patients were diagnosed with adenocarcinoma of the pancreas during the study period. 58.3% of patients were men. The average age was 69.9 years (+10.3). Of the cancer patients, 306 had MRI scans. 63 scans were performed in the 2 months to 2 years prior to diagnosis of cancer. 91.3% of scans were unenhanced. MRI Findings are noted in Table 1 and interobserver agreement in Table 2. Comparing MRI of cancer patients to control patients, a solid mass was identified in 41.3% v. 11.8%, p = 0.024. A cystic lesion was identified in 29% v. 17.6%, p = 0.347. Cysts with mural nodules or septations were noted in 11.1% v. 5.9%, p= 0.46. Pancreatic duct (PD) dilation was noted in 54% v. 17.6%, p=0.007. A PD stricture was identified in 47.6% v. 11.8%, p = 0.007. A duct cut-off sign was noted in 42.9% v. 5.9%, p =0.046. Interobserver agreement (kappa) was >0.7 for PD abnormalities. Conclusions: Abnormal findings including solid masses, cystic masses and PD abnormalities were described in nearly 76% of patients undergoing MRI scanning of the abdomen in the 2 years preceding a diagnosis of cancer. Inter-observer agreement was low for the detection of solid or cystic masses. More agreement was noted for the findings of PD abnormalities. Based on high level of association and interobserver agreement, we suggest PD dilation, PD stricture, and PD cut-off sign as the earliest signs for an underlying pancreatic cancer. Table 1: Frequency of MRI Findings in Pancreatic Cancer Patients and Controls

A Retroperitoneal Bronchogenic Cyst

C left upper-quadrant mass was identified incidentally on computed tomography and magnetic resonance imaging n a 67-year-old man with chronic nephrolithiasis, who was symptomatic from a gastrointestinal standpoint. The 3.9 .7 cm retroperitoneal mass was separate from the pancreas and tomach and showed no contrast enhancement (Figure A, arows: mass; arrowheads: stomach). No extrinsic gastric compresion was identified on endoscopy. Endoscopic ultrasound (EUS) evealed a retroperitoneal hypoechoic mass with internal, diinutive, intensely hyperechoic foci that imparted a starry-sky ppearance (Figure B). Fine-needle aspiration (FNA) was perormed with 5 passes. Viscous clear fluid was obtained. The spirate contained abundant amorphous debris and no maligant or atypical cells. Scant degenerated ciliary tufts were idenified (Figure C). The mass was resected laparoscopically. Hisologic evaluation revealed a fibromuscular cyst wall containing ronchial mucinous glands (Supplementary Figure A). Intraveous ciprofloxacin was given at the time of the procedure and ontinued orally twice daily for 5 days. Bronchogenic cysts are uncommon and originate from abnoral budding and separation of epithelial cells from the tracheoronchial tree during weeks 7 to 12 of embryonic development. he subdiaphragmatic location is even more rare. The majority 82%) of these cysts are located in a triangle behind the stomach efined by the midline, the splenic vein inferiorly, and the spleen/ iaphragm superior/posteriorly.1 On mediastinal foregut duplicaion cysts, 2 EUS patterns were identified: one of an anechoic imple cyst with no obvious debris, and another of an anechoic yst with dense hyperechoic debris.2 Aspirates are characterized by detached ciliary tufts, deenerated cells, needle-like crystals, and amorphous debris. istology shows a fibromuscular cyst wall containing cartiage and/or bronchial mucinous glands lined by benign coumnar-ciliated epithelium. The natural history of these cysts is unknown but the risk of alignancy probably is low. It is possible to diagnose these ysts preoperatively by EUS-FNA. Once a diagnosis of a retroeritoneal bronchogenic cyst is made by EUS-FNA, surgery may ot be necessary; and periodic follow-up evaluation with crossectional imaging probably will be indicated.

Gastric Intussusception Secondary to Fundic Gland Polyposis

A 70-year-old female with a 10-year history of intermittent nausea, vomiting, diarrhea, and chronic proton pump inhibitor (PPI) use presented to the emergency department with an acute episode of epigastric pain. Physical exam was unremarkable and laboratory tests were nonrevealing. Computed tomography of the abdomen revealed a gastrogastric intussusception (Fig. 1). The patient underwent upper endoscopy. Endoscopic evaluation revealed that the intussusception had spontaneously reduced. Additionally, innumerable 6to 25mm pedunculated and sessile polyps from the gastric cardia to the antrum in a carpet-like manner were noted (Fig. 2). Endoscopy also revealed grade C erosive esophagitis with esophageal stenosis using the Los Angeles Classification of Gastroesophageal Reflux Disease. Multiple biopsies of the polyps were performed. Pathology was consistent with fundic gland polyps without adenomatous features. Pathology was negative for Helicobacter pylori. Follow-up colonoscopy was negative for polyps. Intussusception is rare in adults—accounting for only 5% of all cases—with pediatric presentation being the most common. Ninety percent of adult cases typically have a lead point with an underlying associated neoplasm in two thirds of these patients. Intussusception can involve any portion along the gastrointestinal tract but is most commonly reported in the small or large intestine with only a few, scattered case reports of gastrogastric intussusception. We present a rare case of gastrogastric intussusception secondary to fundic gland polyposis. Fundic gland polyps are the most commonly reported gastric polyp, which are non-malignant lesions that may be sporadic or caused by an underlying genetic mutation. Previous reports have also demonstrated an association between PPI