Mohammad K. Ismail

Colorectal Cancer Screening

During the past decade we have seen dramatic advances in colon cancer screening. Reduction in mortality in average risk screening for colorectal cancer has now been shown in multiple trials. Efforts to increase public awareness and compliance with evidence-based screening guidelines are underway. Recent guidelines have incorporated family history, as it has been identified as a common risk factor. The genes responsible for the inherited syndromes of colon cancer have been identified and genetic testing is available. Currently, screening the average risk population over the age of 50 would reduce mortality from colon cancer by 50%. Future advances will likely include improved screening tests, and the development of familial genetic testing.

Granular Cell Tumor of the Esophagus: Report of Five Cases and Review of the Literature

Granular cell tumor (GCT) is an uncommon esophageal neoplasm. It commonly presents as a nonspecific painless mass. The purpose of this study is to describe our experience with 5 patients newly diagnosed with GCT at VA Medical Center in Memphis, Tennessee from February 2001 to June 2005. Clinical manifestation, endoscopic appearance, histology, different modalities of treatment and prognosis are discussed. Based on this experience, we conclude that GCTs are relatively rare in occurrence. They usually present as a firm to hard submucosal nodule on esophagogastroduodenoscopy. Diagnosis can be made by endoscopic biopsy in most cases. Treatment options include endoscopic surveillance, endoscopic resection, or surgery. The usual course of GCTs is benign.

Biliary Strictures After Liver Transplantation. Predictive Factors for Response to Endoscopic Management and Long-term Outcome

Background:Biliary strictures after liver transplantation are frequent. The long-term prognosis and predictive factors of response to endoscopic treatment are not well known. Methods:The aim of this study was to demonstrate the role of endoscopic treatment, predictive factors of response, and outcome in patients with biliary stricture after liver transplantation. We performed a retrospective review of medical records of all consecutive post-liver transplantation patients who underwent endoscopic retrograde cholangiography in our center during the period from October 2001 to October 2006. Results:Twenty-five of 43 patients referred for endoscopic retrograde cholangiography had biliary stricture. Eighteen had stricture at the area of the anastomosis alone, 2 patients had a stricture at the area of the anastomosis and also another area, and 5 had nonanastomotic biliary strictures. Twenty-one patients had a single stricture and 4 had more than 1 stricture. Initially 19 of 24 patients (79%) responded to endoscopic management with normalization of liver enzymes. Four patients (16%) did not respond clinically despite a successful endoscopic approach. All patients who did not respond to endoscopic dilation had more than 1 area of stricture. There was a significantly better response to endoscopic treatment in patients with an anastomotic stricture versus patients with nonanastomotic strictures 17/19 versus 2/5 (P = 0.042). Conclusions:In our experience, endoscopic treatment of anastomotic biliary strictures is highly effective with a good long-term outcome. The presence of nonanastomotic and multiple strictures should be considered a factor associated with poor response to endoscopic management.

A meta-analysis of endoscopic ultrasound–fine-needle aspiration compared to endoscopic ultrasound–fine-needle biopsy: diagnostic yield and the value of onsite cytopathological assessment

Background The diagnostic yield of endoscopic ultrasound (EUS) guided fine-needle aspiration (FNA) is variable, and partly dependent upon rapid onsite evaluation (ROSE) by a cytopathologist. Second generation fine-needle biopsy (FNB) needles are being increasingly used to obtain core histological tissue samples. Aims Studies comparing the diagnostic yield of EUS guided FNA versus FNB have reached conflicting conclusions. We therefore conducted a systematic review and meta-analysis to compare the diagnostic yield of FNA with FNB, and specifically evaluating the diagnostic value of ROSE while comparing the two types of needles. Methods We searched several databases from inception to 10 April 2016 to identify studies comparing diagnostic yield of second generation FNB needles with standard FNA needles. Risk ratios (RR) were calculated for categorical outcomes of interest (diagnostic adequacy, diagnostic accuracy, and optimal quality histological cores obtained). Standard mean difference (SMD) was calculated for continuous variables (number of passes required for diagnosis). These were pooled using random effects model of meta-analysis to account for heterogeneity. Meta-regression was conducted to evaluate the effect of ROSE on various outcomes of interest. Results Fifteen studies with a total of 1024 patients were included in the analysis. We found no significant difference in diagnostic adequacy [RR 0.98 (0.91, 1.06), (I 2 = 51 %)]. Although not statistically significant (P = 0.06), by meta-regression, in the absence of ROSE, FNB showed a relatively better diagnostic adequacy. For solid pancreatic lesions only, there was no difference in diagnostic adequacy [RR 0.96 (0.86, 1.09), (I 2 = 66 %)]. By meta-regression, in the absence of ROSE, FNB was associated with better diagnostic adequacy (P = 0.02). There was no difference in diagnostic accuracy [RR 0.99 (0.95, 1.03), (I 2 = 27 %)] or optimal quality core histological sample procurement [RR 0.97 (0.89, 1.05), (I 2 = 9.6 %)]. However, FNB established diagnosis with fewer passes [SMD 0.93 (0.45, 1.42), (I 2 = 84 %)]. The absence of ROSE was associated with a higher SMD, i. e., in the presence of an onsite pathologist, FNA required relatively fewer passes to establish the diagnosis than in the absence of an onsite pathologist. Conclusions There is no significant difference in the diagnostic yield between FNA and FNB, when FNA is accompanied by ROSE. However, in the absence of ROSE, FNB is associated with a relatively better diagnostic adequacy in solid pancreatic lesions. Also, FNB requires fewer passes to establish the diagnosis.

Bronchobiliary Fistula in a Cirrhotic Patient: A Case Report and Review of the Literature

Bronchobiliary fistula is defined as the passage of bile in the bronchi. The presence of bronchobiliary fistula in patient with cirrhosis is extremely rare. Management of these fistulas is often very difficult and can be associated with high morbidity and mortality. We are presenting a patient with ethanol related cirrhosis and biliptysis in whom a diagnosis of bronchobiliary fistula was made. A review of the literature including diagnosis and management is performed.

Efficacy of self-expandable metal stents in management of benign biliary strictures and comparison with multiple plastic stents: a meta-analysis

Background and study aims There is burgeoning interest in the utilization of covered self-expandable metal stents (CSEMSs) for managing benign biliary stricture (BBS). This systematic review and meta-analysis evaluated cumulative stricture resolution and recurrence rates using CSEMSs and compared performance of CSEMSs and multiple plastic stents (MPS) in BBS management. Method Searches in several databases identified studies including ≥ 10 patients that utilized CSEMSs for BBS treatment. Weighted pooled rates were calculated for stricture resolution and recurrence. Pooled risk ratios (RRs) comparing CSEMSs with MPS were calculated for stricture resolution, stricture recurrence, and adverse events. Pooled difference in means was calculated to compare number of endoscopic retrograde cholangiopancreatographies (ERCPs) in each group.  Results The meta-analysis included 22 studies with 1298 patients. Weighted pooled rate for BBS resolution with CSEMS was 83 % (95 % confidence limits [95 %CLs] 78 %, 87 %; I2 = 72 %). On meta-regression analysis, resolution in chronic pancreatitis patients and post-orthotopic liver transplant patients were significant predictors of heterogeneity. Weighted pooled rate for stricture recurrence with CSEMSs was 16 % (11 %, 22 %). Overall rate of adverse events requiring intervention and/or hospitalization was 15 %. Four randomized controlled trials with 213 patients compared CSEMSs with MPS: the pooled RRs for stricture resolution, recurrence, and adverse events were 1.07 (0.97, 1.18), 0.88 (0.48, 1.63), and 1.16 (0.71, 1.88), respectively with no heterogeneity. Pooled difference in means for number of ERCPs was - 1.71 ( - 2.33, - 1.09) in favor of CSEMS. Conclusions CSEMSs appear to have excellent efficacy in BBS management. They are as effective as MPS but require fewer ERCPs to achieve clinical success.

The Role of Nonsteroidal Anti-inflammatory Drugs in the Prevention of Post Endoscopic Retrograde Cholangiopancreatography Pancreatitis

Post-ERCP pancreatitis (PEP) is the most common major complication associated with ERCP. Beginning with an overview of the risk factors for the development of PEP, this review introduces the mechanism of injury in PEP and the role of pharmacological prevention. NSAIDs are increasingly found to offer prevention against the development of PEP, and their mechanism and supportive data are summarized, especially in relationship to the practice of prophylactic pancreatic duct stenting.

Granulomatosis With Polyangiitis Presenting as Gastric Ulcer: An Unusual Initial Manifestation Successfully Treated With Rituximab

G ranulomatosis with polyangiitis (GPA), previously called as Wegener’s disease, is a systemic vasculitis of unknown etiology affecting medium and small vessels. Classically, it affects upper and lower airways, kidneys, skin, and joints. Granulomatous inflammation combined with positive antineutrophilic cytoplasmic antibodies (ANCA) are characteristic of this disease. Gastrointestinal involvement is extremely rare, and so far, only 3 cases have been reported with stomach involvement. Here, the authors described the 1st case of GPA presenting as gastric ulcer, which was successfully treated with rituximab. A 48-year-old woman presented to the gastroenterology clinic with a 6-month history of abdominal pain, nausea, heartburn, and unintentional 10-pound weight loss. She denied dysphagia, odynophagia, diarrhea, hematemesis, hematochezia, and melena. Physical examination was remarkable only for epigastric tenderness. Esophagogastroduodenoscopy (EGD) revealed a solitary 14-mm deep cratering ulcer in the gastric fundus with congestion and erythema throughout the stomach. Esophageal and duodenal mucosa appeared endoscopically normal. Directed biopsy showed marked active chronic gastritis with deep ulceration associated with scattered lymphoid aggregates and nonnecrotizing granulomatous inflammation with multinucleated giant cells (Figure 1). No Helicobacter species, viral inclusion bodies, acid-fast bacilli, or fungi were identified (corresponding cytochemical and immunohistochemical stains were all negative). Omeprazole was initiated at 40 mg twice daily empirically. The patient presented 2 months later with cough, pleuritic chest pain, and hemoptysis. Chest x-ray showed 2.6-cm lobulated mass in right upper lobe and chest computed tomography (CT) with contrast revealed 2 large necrotic masses: 1 in the right upper lobe, the other is in the mediastinum. Bronchoscopy combined with transbronchial biopsies were negative for malignancy and the bronchoalveolar lavage negative for any bacterial, fungal, and mycobacterial infection. Purified protein derivative (PPD) and Gold quantiferon tests were also negative. Liver chemistries showed alkaline phosphatase 390 (34–104 U/L), AST 44 (13–40 U/L), and ALT 139 (7–52 U/L). Histoplasma serum antibody was positive, but histoplasma urine antigen was negative. Pulmonary service believed that patient has histoplasmosis and started her on empirical oral itraconazole. However, her health status continued to decline. She developed spiking fever, and hemoptysis worsened. She was admitted to the inpatient service, and intravenous (IV) amphotericin-B was initiated after the recommendation of infectious disease service. Repeat EGD showed persistence of the ulcer with further development of a sinus tract expressing exudate and necrotic debris. Biopsies showed mild active chronic gastritis. Again, no microorganisms or viral inclusion bodies were identified. Endoscopic ultrasound was then performed with fine needle aspiration of subcarinal and right paratracheal lymph nodes. No evidence of infection or malignancy was identified. One week into the hospitalization, the patient developed respiratory failure requiring intubation, severe migratory arthralgias, and pruritic skin lesions on the right flank and on both legs. Complete blood count, serum chemistries, urinalysis, hepatitis screen, and human immunodeficiency virus screen were all unremarkable. Antinuclear antibody (ANA) was positive, but specific antibodies were negative and complements were normal. C-ANCA was also positive, and PR3 antibody level was 7.21 (0.8–1.19 AU/mL). Anti-MPO antibody was negative (0.14 [0.0–0.79 AU/mL]). Skin biopsy showed leukocytoclastic vasculitis. At this point, a diagnosis of GPA was established, and the patient was given pulse methylprednisolone 1 g IV daily for 3 days and IV cyclophosphamide 750 mg/m2. She had an excellent clinical response and was promptly extubated and discharged. She was continued on prednisone orally 1 mg

NCCN clinical practice guidelines in oncology. Colorectal cancer screening.

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Genetic/familial high-risk assessment: Colorectal version 1.2016: Clinical practice guidelines in oncology

d21, IV cyclophosphamide 750 mg/m2 monthly for 6 months. At 3-month posthospitalization, the patient appeared to be in remission with dramatic improvement in symptoms, low anti-PR3 titers, near-complete resolution of pulmonary masses on CT, and complete healing of the ulcer on EGD. Prednisone was slowly tapered to 10 mg/d over 6 months while she received IV cyclophosphamide therapy. After the completion of IV cyclophosphamide therapy, methotrexate PO 15 mg/wk was initiated. Although she was on maintenance therapy, follow-up CT chest showed relapse of the necrotic lung lesions although she was completely asymptomatic. She had follow-up bronchoscopy, and Bronchoalveolar lavage (BAL) was negative for mycobacterial and fungal infection. She was treated with rituximab 375 mg/m2 every week for 4 weeks and was started on azathioprine. Approximately 2 years after her initial diagnosis, she is completely asymptomatic and has complete resolution of the lung mass. She is being maintained on azathioprine 150 mg/d. GPA is characterized by necrotizing granulomatous inflammation and vasculitis. It may affect any organ system during its initial presentation but typically involve upper airways, lungs, and/or kidneys. This case is unusual because the sentinel event was a gastric ulcer with granulomatous inflammation, initially unrecognized as a presentation of GPA. It was not until the later part of the disease that the patient developed classic GPA findings and then the original gastric biopsy were attributed to GPA. Interestingly, this patient also had transiently elevated liver enzymes, which improved with cyclophosphamide raising the possibility that she may have had hepatic involvement, but this was not histologically documented as no liver biopsy was performed. Gastrointestinal involvement is extremely rare with stomach involvement as the least often described. Only 3 case reports could be found, and none had gastric ulcer as the initial presentation. Interestingly, none of them had biopsy-proven granulomatous inflammation when compared with this patient. Prednisone combined with cyclophosphamide has been the standard of care to treat GPA for decades. Lately, rituximab has been found to be useful in the treatment of GPA and has been approved by FDA for treatment of ANCA-associated vasculitis. Rituximab has also been found to be useful in the treatment of relapsing disease after treatment with cyclophosphamide. Based on that information, the authors treated their patient with rituximab when she relapsed. She responded well to rituximab, and now, she is being maintained on azathioprine.