Mohamed M. Abdelfatah

Factors Predicting Recurrence of Clostridium difficile Infection (CDI) in Hospitalized Patients: Retrospective Study of More Than 2000 Patients

Background Clostridium difficile infection (CDI) has increased in incidence and severity worldwide, causing direct costs estimated to range from US

Low vitamin D level and impact on severity and recurrence of Clostridium difficile infections.

3.2 billion to

The cellularity yield of three different 22-gauge endoscopic ultrasound fine needle aspiration needles: CELLULARITY YIELD OF THREE DIFFERENT 22-GAUGE ENDOSCOPIC ULTRASOUND FNA NEEDLES

4.8 billion. The aim of this study was to investigate and identify factors that predict recurrence of CDI. Methods This was a retrospective case-control study between 2007 and 2013 on patients admitted with CDI. Recurrent CDI is defined as a new episode of diarrhea within 90 days confirmed by a positive stool C. difficile toxin assay or polymerase chain reaction, after resolution of the initial CDI episode for at least 10 days and after discontinuation of the CDI therapy. Results Three thousand twenty patients were diagnosed with CDI between January 2007 and December 2013. Two hundred nine of 2019 patients in the study had a recurrence of CDI within 90 days of the end of the initial CDI episode (10.3%). Multivariate analysis showed that most of the recurrences occurred in patients with comorbidities, particularly chronic kidney disease (odds ratio, 1.3; 95% confidence interval [CI], 1.0–2.4; P = 0.039). In addition, a higher percentage of patients in the recurrence group were prescribed proton-pump inhibitors (odds ratio, 1.65; 95% CI, 1.0–1.7; P = 0.002) and steroids (odds ratio, 1.65; 95% CI, 1.0–1.5; P = 0.047). Conclusions Our data suggest that the use of glucocorticoids, use of proton-pump inhibitors, and having end-stage renal disease are significant risk factors associated with recurrent CDI.

Hemobilia: a rare cause of intermittent biliary obstruction

Background Clostridium difficile infection (CDI) has recently markedly increased, incurring greater health care–associated costs and hospitalizations especially in vitamin D deficient patients. Accordingly, the aim of this study was to evaluate the relationship between low vitamin D levels and the severity and recurrence of CDI. Methods A retrospective case-control study evaluated patients hospitalized between 2007 and 2013 with CDI and a positive C. difficile toxin assay. Severe complicated CDI was defined based on (1) laboratory or radiological criteria correlated clinically and (2) sepsis requiring intensive care unit admission. Recurrent CDI (RCDI) was defined as a new episode of diarrhea occurring within 90 days of resolution of the initial episode for at least 10 days after discontinuing therapy and confirmed by positive stool C. difficile toxin assay or polymerase chain reaction. Patients were divided into 4 groups based on vitamin D level (ng/mL): severely deficient (<10), insufficient (10-19.9), predeficient (20-29.9), and control group (≥30). Results Two hundred seventy-one patients were diagnosed with CDI, of which 48 had RCDI distributed as 5 (12.5%), 15 (16.1%), 10 (15.6%), and 13 (17.5%) patients in each of the aforementioned groups, respectively (P= 0.55). Severe complicated CDI was identified in 7 (17.5%), 17 (18.2%), 9 (14%), and 3 (4%) patients, respectively (P = 0.04). Thirty-day mortality was 1 of 40, 1 of 93, 2 of 64, and 2 of 74 patients, respectively (P = 0.43). Conclusions Normal vitamin D level has a protective effect against severe CDI, and low vitamin D is associated with greater severity of CDI but not with an increased risk of RCDI or 30-day mortality.

Endoscopic ultrasound-guided hepaticogastrostomy and antegrade clearance of biliary lithiasis in patients with surgically-altered anatomy

Endoscopic ultrasound (EUS) fine needle aspiration (FNA) is an integral part in the diagnosis of pancreatic, intestinal and extra‐intestinal masses or lesions. There is no clear data on the superiority of the core biopsy needle over standard 22‐gauge needles. The aim of this study is to prospectively compare the cellularity yield of three commonly used 22‐gauge FNA needles available in the US market. Methods: This is a prospective, randomized study comparing the cellularity yield of three commercially available EUS needles (two standard FNA needles and core biopsy needle). Two blinded pathologists evaluated the cytology specimens based on an already agreed upon cytology score. We included adult patients (18–80 years old) who presented to our endoscopy unit for FNA of pancreatic or extrapancreatic masses.

Leiomyosarcoma Involving the Pancreas Diagnosed by Endoscopic Ultrasound Fine-Needle Aspiration

A 48-year-old man with a medical history of metastatic small-bowel neuroendocrine tumor, who was using chemotherapy, presented with nausea, vomiting, and right upperquadrant abdominal pain. His laboratory tests demonstrated abnormal liver enzymes (bilirubin 2.7 mg/dL, alkaline phosphatase 187 mg/dL, aspartate aminotransferase 174 mg/dL, and alanine aminotransferase 89mg/dL). He had a low hemoglobin of 10.6mg/dL.His liver enzymes andhemoglobinwere normal 1 week before the presentation. He underwent US of the abdomen and a CT scan of the abdomen without contrast material because of his worsening kidney function. US and CT without contrast material revealed newly diagnosed liver metastasis. MRCP demonstrated prominence of the intrahepatic duct. During the hospital stay, his liver function normalized and his abdominal pain resolved; he was discharged home. Two days later he was seen because of recurrence of abdominal pain and worsening of liver enzymes (bilirubin 4 mg/dL, alkaline phosphatase 366mg/dL, aspartate aminotransferase 125 mg/dL, and alanine aminotransferase 145 mg/dL). A hepato-iminodiacetic acid scan, obtained to rule out biliary obstruction as a cause of his elevated liver enzymes, revealed prompt liver uptake without excretion, suggestive of high-grade biliary obstruction. ERCPwas performed, and bloodwas noted at the ampulla, raising suspicion for hemobilia (Fig. 1A). The common bile

What Do We Need to Know About Colonic Polypoid Ganglioneuroma? A Case Report and A Comprehensive Review

Background and study aims  Endoscopic retrograde cholangiography (ERC) in patients with complex surgically-altered anatomy (SAA) is technically demanding and has limitations. Developments in EUS-guided procedures allow alternative approaches for patients with altered gastrointestinal anatomy and biliary lithiasis. Patients and methods  Single-center, retrospective review of prospectively entered patients with SAA who underwent EUS-guided hepaticogastrostomy (HGS) followed by an interval antegrade endoscopic clearance of biliary lithiasis. Results  9 patients with Roux-en-Y anatomy underwent HGS to allow clearance of biliary lithiasis after a mean of 2.5 procedures. Technical success was achieved in 100 % of patients utilizing subsequent antegrade endoscopic techniques after HGS including: balloon sweep (9), transpapillary balloon dilation (8), cholangioscopy with electrohydraulic lithotripsy (4), and mechanical lithotripsy (1). HGS stents were removed in all patients. 1 adverse event (cholangitis) occurred after cholangioscopy and prolonged intraductal electrohydraulic lithotripsy. Conclusion  EUS-guided antegrade therapy for the management of biliary lithiasis in patients with altered gastrointestinal anatomy appears efficacious with a low risk of adverse events. These preliminary results suggest this approach should be considered at centers with available expertise.

The diagnostic and cellularity yield of reverse bevel versus fork-tip fine needle biopsy

Soft tissue sarcomas are rare tumors that usually affect the extremities but can occasionally present as retroperitoneal masses [1]. Pancreatic leiomyosarcoma (PLMS) is an exceptionally uncommon neoplasm that accounts for only 0.1% of all pancreatic malignancies [2, 3]. To date, 70 patients have been diagnosed with leiomyosarcoma of the pancreas reported in the literature. Almost all of the cases were diagnosed after resection or by biopsy. Endoscopic ultrasound fine-needle aspiration (EUS-FNA) has proven to be a safe and effective method for diagnosing neoplasms within or adjacent to the gastrointestinal tract [2]. We report the third case of leiomyosarcoma involving the pancreas and extending into the porta hepatis that was successfully diagnosed using EUS-FNA cytology [4, 5].

Relief of dysphagia due to advanced achalasia by endoscopic creation of an esophagogastric bypass anastomosis through an epiphrenic diverticulum

Intestinal ganglioneuromas (GNs) are rare well-differentiated, slowly growing neuroectodermal neoplasms mainly formed of nerve fibers, ganglion cells, and supporting cells [1]. There are three types of GNs: polypoid GNs, ganglioneuromatous polyposis, and diffuse ganglioneuromatosis. Polypoid GNs are the most common type and are typically found incidentally on colonoscopies as a solitary polyp involving the mucosa and submucosa that could resemble an adenoma, a hyperplastic, or a juvenile polyp. Ganglioneuromatous polyposis is characterized by more than 20 sessile or pedunculated mucosal or submucosal lesions that endoscopically resemble familial adenomatous polyposis. Diffuse ganglioneuromatosis is a large poorly-demarcated nodular and disseminated proliferation of ganglioneuromatous tissue [1]. Typically, ganglioneuromatosis are large (up to 17 cm), poorly demarcated, and often infiltrate the adjacent bowel wall and distort the surrounding tissue architecture. Ganglioneuromas can be found anywhere in the body, although involvement of the GI tract is a rare occurrence. Most patients with GNs are asymptomatic and are usually discovered on screening colonoscopies, although rarely may present with gastrointestinal symptoms such as abdominal pain, constipation, weight loss, bleeding, or obstruction depending on the size and location of the polyp. The diagnosis of GN is based on the recognizing ganglion cells with hematoxylin and eosin stain. NSE and S100 protein are essential in confirming and evaluating the extent of the lesion. The differential diagnosis of these lesions includes neurofibromas and schwannomas, both of which lack ganglion cells [2]. GNs have been detected in patients with multiple endocrine neoplasia (MEN) type IIb [3], Cowden syndrome(CS) [4], familial adenomatous polyposis coli [5], tuberous sclerosis [6], and neurofibromatosis type 1 (NF-1) [1, 7]. Current guidelines have no specific recommendations to directly address GNs, especially in the setting of finding solitary polypoid GNs during routine screening. Moreover, GNs have an association with hereditary syndromes and possibly an increased risk of malignancies. In this report, we present a case of solitary colonic ganglioneuroma found during a routine screening colonoscopy with a current literature review with the goal of providing some guidance to gastroenterologists when they encounter this diagnosis.

Correlation between adenoma detection rate and novel quality indicators for screening colonoscopy. A proposal for quality measures tool kit

Two new systems with a novel tip (Procore™ and SharkCore™) have been introduced for ultrasound‐guided fine needle biopsy (US‐FNB). Direct comparison of the diagnostic yield of these needles in the evaluation of pancreatic lesions is currently under investigation. This study aims to compare the diagnostic and cellular yields of the two needle systems.