Matthew W. Stier

Post-ablation surveillance in Barrett's esophagus: A review of the literature

Barretts esophagus (BE) is a pre-malignant condition affecting up to 15% of patients with gastroesophageal reflux disease. Neoplastic Barretts mucosa is defined as harboring high grade dysplasia or intra-mucosal cancer, and carries a high risk of progression to esophageal adenocarcinoma. The rising incidence of Barretts lesions along with the high morbidity of surgical approaches has led to the development of numerous validated endoscopic techniques capable of eradicating neoplastic mucosa in a minimally invasive manner. While there has been widespread adoption of these techniques, less is known about optimal surveillance intervals in the post-therapy period. This is due in part to limitations in current surveillance methods, questions about durability of treatment response and the risk of subendothelial progression. As we are now able to achieve organ sparing eradication of superficial neoplasia in BE, we need to also then focus our attention on how best to manage these patients after eradication is achieved. Implementing optimal surveillance practices requires additional understanding of the biology of the disease, appreciation of the limits of current tools and treatments, and exploration of the role of adjunctive technologies. The aim of this article is to provide a comprehensive review of current literature surrounding post-ablation surveillance in neoplastic BE.

Transected nasogastric tube: a rare complication of nasogastric feeding

A 70-year-old woman was hospitalized with failure to thrive. Her recent history included bereavement and protein-calorie malnutrition. Her body mass index was 17 kg/m2. She was oriented only to person. Laboratory tests showed hypernatremia and prerenal azotemia. A nasogastric (NG) feeding tube was placed successfully on hospital day 3 (Fig. 1), and enteral feeding was commenced. The patient’s mental status improved to tolerate an oral diet with bedside removal of the tube on hospital day 11; however, a portion of the distal tubing was missing. An abdominal X-ray study showed 8 cm of retained tubing in the stomach (Fig. 2). An esophagogastroduodenoscopy (EGD) was performed with foreign body extraction using a rat-tooth forceps (Figs. 3 and 4). She was discharged the following day. One prior case report describes a fractured orogastric tube after intraoperative placement [1], while another reports nasojejunal tube fracture [2]. Our case describes spontaneous transection of NG tubing after successful placement and 8 days of enteral feeding, without resistance upon removal. The mechanism of transection is unclear. The American Society for Gastrointestinal Endoscopy recommends urgent endoscopy for objects > 6 cm above the proximal duodenum, which was performed in this case [3]. This recommendation

Calciphylaxis in end-stage liver and renal disease patients before and after transplant

Calciphylaxis is a rare vascular disorder characterized by calcification of arterioles which causes tissue inflammation and necrosis. It is associated with the metabolic disturbances seen in end‐stage renal disease (ESRD) and has also been described in patients with cirrhosis with preserved kidney function. Characteristic calciphylaxis lesions are black eschars surrounded by retiform purpura, and the gold standard for diagnosis is skin biopsy. Reported 1‐year mortality rates range between 45% and 80%. No treatment modality has been evaluated in a prospective randomized trial, and reports of treatment efficacy vary. Kidney transplant has been reported as a successful therapy for calciphylaxis; however, cases exist of the initial onset of calciphylaxis following kidney transplant as well as simultaneous liver‐kidney (SLK) transplant. The decision to maintain a patient with end‐stage renal and liver disease on the waiting list for SLK transplant following the onset of calciphylaxis must consider the high 1‐year mortality associated with this condition. More research is necessary to understand how to allocate donor allografts to manage patients with calciphylaxis and ESRD and/or cirrhosis effectively.

A Diagnosis of Small Bowel Polyposis

Gastroente Question: A 19year-old Hispanic man presented to the emergency department with nausea and vomiting. He was treated initially for viral gastroenteritis but returned several days later with intussusception and small bowel obstruction that was managed conservatively. Two months later, symptoms recurred with a 30-pound weight loss and intermittent hematochezia. An intussusception was again noted on imaging. An exploratory laparotomy was performed and a segment of the jejunum from the Ligament of Treitz to 25 cmwith carpeting polypswas resected (FigureA). Pathology showed hamartomatous polyps containing foveolar and gastric-type tissue with arborizing streaks of smooth muscle and minimal inflammation (Figure B). He denied history of cognitive delay, dermatologic lesions, or mucocutaneous freckling. His family history was notable for a paternal grandmother with pancreatic cancer at age 70 but no history of gastrointestinal polyps. On physical examination, he was well developed (6’2” and 225 pounds) with a head circumference of 62 cm (>97th percentile). Other than a well-healed surgical scar, abdominal, skin, genital, and neurologic examinations were normal. An upper endoscopy was performed and showed Helicobacter pylori gastritis. Colonoscopy and capsule endoscopy revealed only lymphoid follicles in the terminal ileum but no other polyps in the small or large intestine. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.