Mohamed Sultan

Ipilimumab associated colitis: An IpiColitis case series at MedStar Georgetown University Hospital

Although ipilimumab has been shown to improve survival in patients with metastatic melanoma and cause regression of metastatic renal cell carcinoma, the associated immune-related toxicities are of concern. The resultant T cell activation by this monoclonal antibody causes an increased immune response, which has been associated with many immune-regulated adverse effects. One of the most concerning effects is the development of colitis. Upwards to 8% of patients have been reported to develop colitis, with 5% being severe (Grades 3-4). While initial treatment of such adverse effects is generally comprised of supportive and symptomatic treatment, more severe cases warrant the use of high dose steroids. Furthermore, use of anti-TNF agents is usually reserved for those cases that prove to be refractory to steroids. We describe a systematic case review of seven patients who developed gastrointestinal symptoms following initiation of ipilimumab immunotherapy, and present the steps in their evaluation, treatment and outcomes at our institution.

Diagnosis and Management of Common Gastrointestinal Tract Infectious Diseases in Ulcerative Colitis and Crohnʼs Disease Patients

Abstract:Management of inflammatory bowel disease (IBD), including ulcerative colitis and Crohns disease, stretches beyond control of flares. Some infections of the gastrointestinal tract are more commonly seen in patients with IBD. Work from the Human Microbiome Project has been instrumental in our understanding of the interplay between the vast gut microbiota and host immune responses. Patients with IBD may be more prone to infectious complications based on their underlying inflammatory disease and variations in their microbiome. Immunosuppressant medications commonly used to treat patients with Crohns and colitis also play a role in predisposing these patients to acquire these infections. Here, we present a detailed review of the data focusing on the most common infections of the gastrointestinal tract in patients with IBD: Clostridium difficile infections (CDI) and cytomegalovirus (CMV). We will discuss appropriate diagnostic tools and treatment options for these infections. Other less common infections will also be reviewed briefly. Studying the various infections of the gastrointestinal tract in these patients could enhance our understanding of the pathophysiology of IBD.

Lymphangioma Presents as Peripancreatic Cystic Neoplasm: The Utility of Endoscopic Ultrasound

Pancreatic lymphangiomas are very rare benign cystic lesions that arise from abnormal proliferation of the lymphatic vessels. Although benign, pancreatic lymphangiomas may mimic more concerning cystic neoplasms and therefore require a thorough diagnostic workup. Herein we report a case of a 50-year-old female who presented with a peripancreatic cyst measuring 2.5x3.6x4.7cm that was discovered incidentally during an abdominal ultrasound. She underwent endoscopic ultrasound with fine needle aspiration where chylous fluid was drained. Cytology was negative for malignancy and fluid chemistry demonstrated a significantly elevated triglyceride level consistent with a pancreatic lymphangioma. It is unclear whether asymptomatic pancreatic lymphangiomas are best managed conservatively or with surgical intervention. The patient has not proceeded with surgery at this time.

Gastric Outlet Obstruction Caused by Prolapsed Gastric Polyp Into the Pyloric Channel

A54-year-old morbidly obese African American woman with a significant past medical history of sarcoidosis, hypertension, and congestive heart failure presented to the emergency room with a 1-week history of abdominal pain, nausea, and vomiting. The patient had moderate tenderness to palpation of the right upper and left upper quadrants on physical examination, with no rebound or guarding. A computerized tomography scan of the abdomen was obtained in the emergency room that showed gastric outlet obstruction and possible intussusception (Figure A). An upper endoscopy showed multiple pedunculated gastric polyps varying in size from 5 to 40 mm. One pedunculated polyp appeared to have prolapsed into the duodenal bulb, causing complete gastric outlet obstruction (Figure B). Multiple maneuvers were not successful in pulling the polyp back into the stomach, including grasping the stalk with a foreignbody forceps, snare, epinephrine injection to shrink the polyp, suction using a banding cap, and the use of glucagon intravenously. A repeat esophagogastroduodenoscopy (EGD) was performed the next day with plans to attempt different maneuvers under fluoroscopy, however, on repeat endoscopy, the polyp appeared to have spontaneously flipped back into the stomach (Figure C) and subsequently was removed with a hot snare. The patient noted a significant improvement in abdominal pain after polyp removal, and was able to tolerate diet well. The pathology of the removed polyp was consistent with a tubular adenoma with intramucosal focal invasive adenocarcinoma. Surgery was considered high risk in view of the patient’s multiple risk factors. Because of the presence of multiple gastric polyps, the patient underwent sequential EGDs with polypectomy. All polyps showed invasive adenocarcinoma that had reached the stalk margin. The patient was deemed high risk for surgery because of her morbid obesity, frequent asthma attacks, and because of possible distant spread. Computerized tomography of the abdomen, pelvis, and chest showed liver lesions and mediastinal lymph nodes. An endoscopic ultrasound–guided fine-needle aspiration of the liver and the mediastinal lymph nodes was performed, however, it showed a granuloma, which was consistent with sarcoidosis but could not exclude metastatic disease. The patient currently is receiving chemotherapy. Gastric polyps are found in approximately 6% of all upper-endoscopy procedures in the United States. In the vast majority of cases, gastric polyps are asymptomatic. However, in some cases, gastric polyps can present with gastrointestinal bleeding, and, less commonly, with gastric outlet obstruction. Pyloric obstruction has been described in case reports as a manifestation of pedunculated polyps in the gastric antrum intermittently prolapsing into or through the pylorus. In our patient, based on her symptoms, images, and the endoscopic findings, it appears that the polyp had prolapsed and

Retroperitoneal Schwannoma Presents as a Peripancreatic Cystic Structure: The Utility of EUS/FNA in the Diagnosis

Retroperitoneal schwannomas are extremely rare tumors that arise from the Schwann cell of the peripheral nerves. Patients are typically asymptomatic, however, large tumors may lead to the development of abdominal pain or obstructive symptoms. Herein we describe a case of a 57 year-old male with a known peripancreatic cystic mass presenting with new onset abdominal pain and a CT demonstrating a 40 × 42 mm peripancreatic cystic structure previously 17 × 20 mm. Endoscopic ultrasound with fine needle aspiration was performed and cytological examination revealed a peripheral nerve sheath tumor. The patient underwent uneventful laparoscopic resection. Analysis of the surgical specimen revealed a spindle cell tumor with positive S100, negative CD117/CD34 and pancytokeratin consistent with a schwannoma

Gastric Duplication Cyst With Elevated Amylase: An Unusual Presentation Mimicking Pancreatic Cystic Neoplasm.

Enteric duplication cysts (EDCs) are benign congenital anomalies that are found incidentally in adults. Gastric duplication cysts (GDCs) are the least common subtype of EDC, but when located near the pancreas, may resemble other neoplastic conditions. We report a case of GDC adjacent to the pancreas with high cystic fluid amylase and carcinoembryonic antigen (CEA) and 3 different epithelia (respiratory, gastric, and intestinal), all diagnosed via endoscopic ultrasound with fine-needle aspiration.

Endosonographic Findings in Colitis Cystica Profunda

A 27-year-old male was referred to our institution for further evaluation of persistent rectal bleeding. A prior colonoscopy showed a sigmoid soft tissue lesion, and pathology revealed chronic active colitis and granulation tissue with ulcers and focal adenomatous changes. We performed a flexible sigmoidoscopy that showed a 4.5-cm multilobulated polypoid lesion approximately 45 cm from the anal verge (Figure 1). A 20 MHz Olympus endoscopic ultrasound (EUS) miniprobe showed hypoechoic lesion with cystic/spongy features involving the mucosa and submucosa (Figure 2). These features were thought to suggest colitis cystica profunda (CCP). Histologic examination of snare biopsies identified dilated glands with mucinous content, surrounded by variable degrees of fibrosis on a background of interspersed chronic inflammatory cells, with few colonic mucosal crypts and mild inflammatory cell infiltrate (Figure 3). The patient was instructed to follow up with gastroenterology if bleeding recurred.