Mohamed A. Mekky

Diagnostic utility of EUS-guided FNA in patients with gastric submucosal tumors

BACKGROUND Submucosal tumors (SMTs) comprise both benign and malignant lesions, and most of the gastric lesions tend to be malignant. The addition of EUS-guided FNA (EUS-FNA) has the potential to improve this distinction, but published series are limited. OBJECTIVE To evaluate the yield of EUS-FNA in gastric SMTs with referral to a criterion standard final diagnosis. DESIGN Retrospective study. SETTING Tertiary-care referral center. PATIENTS This study involved 141 consecutive patients with gastric SMTs, who underwent EUS-FNA from January 2000 to December 2008. Immunohistochemical staining with c-kit, CD34, actin, and S-100 antibodies was done if a spindle cell tumor was found. Based on FNA sample adequacy, and whether a specific diagnosis could be established, EUS-FNA results were categorized as diagnostic, suggestive, or nondiagnostic. The criterion standards for final diagnosis were the surgical histopathological results or the follow-up course for malignant, inoperable cases. INTERVENTION EUS-FNA. MAIN OUTCOME MEASUREMENTS Diagnostic yield of EUS-FNA and factors related to sampling adequacy for cytological and immunohistochemical evaluation. RESULTS A total of 141 patients (52% female, mean age 56.7 years) underwent EUS-FNA (range 1-5 passes). The overall results of EUS-FNA were diagnostic, suggestive, and nondiagnostic in 43.3%, 39%, and 17.7% of cases, respectively. Adequate specimens were obtained in 83% of cases, and 69 cases (48.9%) had a definitive final diagnosis. The most common gastric SMT was GI stromal tumor (59.5%). EUS-FNA results were 95.6% accurate (95% confidence interval [CI], 87.5%-99%) for the final diagnosis and 94.2% (95% CI, 85.6%-98.1%) accurate for differentiating potentially malignant lesions. A heterogeneous echo pattern was the only independent predictor for sampling adequacy (adjusted odds ratio 6.15; P = .002). There were no procedure-related complications. LIMITATIONS Possibility of selection bias. CONCLUSION EUS-FNA is an accurate method for diagnosis of gastric SMTs and for differentiating malignant lesions.

Can EUS-guided FNA distinguish between gallbladder cancer and xanthogranulomatous cholecystitis?

BACKGROUND EUS-guided FNA (EUS-FNA) is a useful modality for sampling various targets, but its applicability to gallbladder (GB) mass lesions is limited. OBJECTIVE To determine the usefulness of EUS-FNA for diagnosing GB mass lesions. DESIGN Single-center, retrospective, case-series study. SETTING Tertiary-care referral center. PATIENTS This study involved 15 consecutive patients who underwent EUS-FNA of GB mass lesions. We punctured GB masses in patients with suspected xanthogranulomatous cholecystitis to distinguish them from malignancy, and in patients with unresectable GB carcinoma for pathological confirmation. The final diagnosis was based on surgical histopathological results or follow-up outcome. INTERVENTIONS EUS-FNA. MAIN OUTCOME MEASUREMENTS Evaluation of EUS-FNA sampling adequacy rate and diagnostic yield. RESULTS Xanthogranulomatous cholecystitis was suspected in 6 of the 15 patients. EUS-FNA revealed foam cells (n = 3), inflammatory cells (n = 1, proven by cholecystectomy), and GB carcinoma (n = 1), and the amount of the aspirate was insufficient in one case (xanthogranulomatous cholecystitis was later proven by extended hepatectomy). The mean follow-up period of the patients with xanthogranulomatous cholecystitis was 1177 days. Adenocarcinoma was confirmed by EUS-FNA in 8 of the 9 patients with suspected unresectable GB carcinoma, and the FNA was inconclusive in one. All 10 patients with GB carcinoma underwent chemotherapy. The overall sampling adequacy was 86.6%. The accuracy of EUS-FNA for detecting malignancy and for the final diagnosis was 93.3% (95% CI, 62.4%-99.9%) and 80% (95% CI, 54%-93.7%), respectively. LIMITATIONS A small patient cohort and a retrospective design with potential selection bias. CONCLUSIONS Malignant GB mass lesions can be safely and accurately differentiated by EUS-FNA. Thus, patients with xanthogranulomatous cholecystitis can avoid undue extensive surgery.

Role of Endoscopic Ultrasound and Endoscopic Ultrasound-Guided Fine-Needle Aspiration in Diagnosing Metastasis to the Pancreas: A Tertiary Center Experience

Background: Metastasis to the pancreas (MP) is a rare entity that is difficult to identify by imaging alone. Few reports have described endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration (FNA) findings. Herein, we try to describe the EUS and EUS-FNA characteristics of MP. Methods: This retrospective study compared 28 patients with MP (13 males; mean age: 60.1 ± 12.6 years) and 60 control patients (30 males; 62.7 ± 11.5 years) with pancreatic ductal adenocarcinoma (PDAC). All lesions were characterized by EUS, and MP was diagnosed by EUS-FNA (n = 16), surgery (n = 6) or both (n = 6). Results: Multivariate logistic regres- sion revealed that the presence of regular borders (p = 0.004; OR: 8.81, 95% CI: 1.97–39.4), the absence of retention cysts (p = 0.045; OR: 12.5, 95% CI: 1.06–147.0), and the absence of main pancreatic duct (MPD) dilation (p = 0.003; OR: 8.18, 95% CI: 2.04–32.8) were predictors of MP rather than PDAC. The EUS-FNA sampling adequacy was 95.4% (21/22), and the correct diagnosis was obtained in 95.2% (20/21) of cases when K-ras mutation analysis and/or immunostaining were added. Conclusion: The presence of regular borders, the absence of retention cysts and the presence of nondilated MPD on EUS indicate MP rather than PDAC. This diagnosis can be accurately confirmed by EUS-FNA with immunostaining and/or K-ras analysis.

Association of colonic regulatory T cells with hepatitis C virus pathogenesis and liver pathology

Forkhead box protein P3 (FoxP3)+ regulatory T (Treg) cells play a fundamental role in maintaining the balance between the tissue‐damaging and protective immune response to chronic hepatitis C (CHC) infection. Herein, we investigated the frequency of Treg cells in the colon and their potential relationship to the various CHC outcomes and hepatic histopathology.

Human Fascioliasis: A Re-emerging Disease in Upper Egypt

In recent years, the number of humans infected with Fasciola has risen rapidly. Diagnosis is based mainly on detection of eggs in stool analysis. The rate of infection in Egypt is unknown. In this retrospective study, we describe 23 cases of hepatic fascioliasis, and only 2 of these cases showed eggs in stools. The symptoms of infection, such as pyrexia of unknown origin, epigastric pain, and abdominal distension, were suggestive. Imaging techniques, including abdominal ultrasonography and computed tomography, were very helpful in detecting hepatic changes. An indirect hemagglutination assay proved to be of value for diagnosis. Treatment using a 2-day triclabendazole regimen cured the infection and signs of hepatic involvement disappeared. Combining both imaging techniques and laboratory tests is essential for diagnosis of fascioliasis in the early stage.

Endoscopic ultrasound in gastroenterology: From diagnosis to therapeutic implications

Since its advent in 1980, the scope of endoscopic ultrasound (EUS) has grown to include a wide range of indications, and it is now being incorporated as an integral part of everyday practice in the field of gastroenterology. Its use is extending from an adjuvant imaging aid to utilization as a therapeutic tool for various gastrointestinal disorders. EUS was first used to visualize remote organs, such as the pancreas and abdominal lymph nodes. When fine needle aspiration was introduced, the indications for EUS expanded to include tissue sampling for diagnostic purposes. At the same time, the needle can be used to convey a potential therapy to the internal organs, allowing access to remote sites. In this review, we aim to highlight the expanding spectrum of EUS indications and uses in the field of gastroenterology.

Virologic and histologic characterisation of dual hepatitis B and C co-infection in Egyptian patients

BACKGROUND AND STUDY AIMS Data about dual hepatitis C (HCV) and B (HBV) co-infection are still scarce, especially in endemic areas such as Egypt. Therefore, we aimed to characterise the virologic and histologic pattern of dual B/C co-infection in a tertiary care centre in Egypt. PATIENTS AND METHODS After obtaining approval from the review board, a retrospective design to evaluate the data registry between January 2009 and December 2012 of patients with dual HCV and HBV seropositivity (BC-group) at the Viral Hepatitis Unit in Ministry of Health and Assiut University Hospital, Egypt was conducted. Data for hepatitis B e antigen (HBe-Ag) and anti-HB core status, anti-hepatitis delta virus (anti-HDV), HBV-DNA and HCV-RNA assays and liver biopsy (METAVIR scoring) results were collected. Two other matched groups of mono-HCV (C-group) and HBV (B-group) were selected as controls. All patients were naive for antiviral therapy. RESULTS A total of 3300 patients were enrolled. Dual infection was observed in 25 (0.7%) patients (all males, mean=35.2±10.2years). Four patients (16%) were HBe-Ag-positive. Six (24%) patients were HBV-DNA-negative and all were positive for HCV RNA. Between groups, raised alanine aminotransferase (ALT) was found in 76%, 41.7% and 49.2% of the BC, B and C groups, respectively (p=0.023). HBV DNA >2000IUml(-1) was more in the B-group than in the BC-group (63.9% vs. 36%; p=0.042) and HCV RNA >800,000IUml(-1) was more in the BC-group than in the C-group (28% vs. 12.3%; p=0.009). Histologically, there is no statistical significant difference between the three groups. CONCLUSION Dual hepatitis B/C infection is not uncommon and their virologic and histologic profile is modest. Further evaluation with regard to treatment and long-term follow-up is warranted.

Contrast-enhanced endoscopic ultrasonography (CE-EUS) findings in adrenal metastasis from renal cell carcinoma.

Solitary adrenal metastasis is often difficult to distinguish from benign adrenal tumor using only plain computed tomography (CT) scanning. We describe a solitary left adrenal gland mass in a patient who had undergone simultaneous gastrectomy and right nephrectomy for advanced gastric cancer and renal cell carcinoma (RCC), respectively. Contrast-enhanced endoscopic ultrasonography (CE-EUS) findings indicated a hypervascular adrenal mass, and EUS-guided fine needle aspiration (EUS-FNA) revealed clear cell carcinoma. Adrenalectomy confirmed metastatic clear cell carcinoma of the kidney.

To treat or not to treat the "immunotolerant phase" of hepatitis B infection: A tunnel of controversy

Hepatitis B virus (HBV) infection is a global public health problem, with an estimated 350 million people worldwide chronically infected and approximately 500000 who die annually from HBV-related liver diseases. Management of chronic HBV is challenging and waves of guidelines emerge every year. One of the hottest topics and a matter of debate is the management of patients in their early immunotolerant phase of infection. With the lack of evidence, dealing with this particular subset of patients creates a great conflict with opposing views. In this review, the author highlights the pros and cons of these views and proposes a reasonable solution to resolve this dilemma.

Study of the impact of viral load of hepatitis C on patients with concomitant psoriasis vulgaris.

BACKGROUND AND STUDY AIM Concomitant hepatitis C virus (HCV) infection and psoriasis vulgaris (PV) are not uncommon coexisting diseases, especially in areas with high viral hepatitis endemicity. To date, data about the interaction between both diseases are scarce. Therefore, we aimed to describe the possible interplay between the HCV viral load and psoriatic activity in concomitant Egyptian diseased patients. PATIENTS AND METHODS Between December 2011 and August 2013, all psoriatic patients attending Assiut University Hospital outpatient clinics were tested for HCV serologic assay. Patients with positively coexisting diseases were further reevaluated for psoriasis area severity index (PASI) score assessment, liver function tests, HCV-RNA-polymerase chain reaction (PCR) assays, and sonographic examination of the liver. For comparative purposes, another matched group (n=26) with psoriasis only (HCV-negative group) was enrolled as a control. RESULTS During the period of the study, 20 patients with concomitant PV and HCV infection (HCV-positive group; 50% males, mean age of 44.15±10.66 years) were recruited. The mean PASI score was 44.75±10.38 and clinical signs of liver dysfunction were observed in 40% (n=8), 100% had abnormal liver function tests (n=20), and 75% had sonographic findings of cirrhosis (n=15). The PASI score was significantly higher in the HCV-positive psoriatic group compared to the HCV-negative control (p<0.001). Significant correlations were detected between the PASI score and the viral loads, and also with alanine aminotransferase (ALT). CONCLUSION When HCV was found concomitantly with PV, a high possibility of severe disease pattern will be expected that entails special precautions in the treatment process.