Muslim Atiq

Role of endoscopic ultrasonography in evaluation of metastatic lesions to the pancreas: A tertiary cancer center experience

Objectives Metastatic lesions to the pancreas pose diagnostic challenges with regards to their differentiation from primary pancreatic cancer. Data on the yield of endoscopic ultrasonography (EUS)–guided fine-needle aspiration in detection of these lesions are limited. Methods This is a retrospective review of 23 patients referred to a tertiary referral center for further evaluation of suspected pancreatic metastases. Main outcome measures were diagnostic yield of endoscopic ultrasonography–guided fine-needle aspiration in evaluation of metastatic lesions to the pancreas. Results Of 644 patients, 23 (3.6%) undergoing EUS of the pancreas were diagnosed to have metastatic disease to the pancreas based on clinical, radiological, and cytological results. Mean (SD) age was 64.3 (11.7) years. Of the 23 patients, 18 (78.3%) were asymptomatic. Mean (SD) size of lesion on EUS was 39.1 (19.9) mm. A diagnosis of malignant lesion was made in 21 of 23 cases, with a diagnostic accuracy of 91.3%. Conclusions Metastatic lesions to the pancreas present as incidental, solitary mass lesions on staging or surveillance imaging. Endoscopic ultrasonography–guided fine-needle aspiration is an important tool in the characterization and further differentiation of metastatic lesions to the pancreas from primary pancreatic cancer.

Biliary tract complications after liver transplantation

Biliary tract complications are an important source of morbidity after liver transplantation, and present a challenge to all involved in their care. With increasing options for transplantation, including living donor and split liver transplants, the complexity of these problems is increasing. However, diagnosis is greatly facilitated by modern noninvasive imaging techniques. A team approach, including transplant hepatology and surgery, interventional endoscopy and interventional radiology, results in effective solutions in most cases, such that operative reintervention or retransplantation is rarely required.

Glycogenic Hepatopathy: Thinking Outside the Box

Glycogenic hepatopathy (GH) remains underrecognized in adults as most clinicians mistake it for the more common hepatic abnormality associated with uncontrolled diabetes mellitus in this age group, non-alcoholic fatty liver disease. This is also complicated by the fact that both entities are indistinguishable on liver ultrasound. We herein describe a similar predicament in which a young adult female presented with bilateral upper quadrant abdominal pain, tender hepatomegaly, lactic acidosis and a >10-fold increase in liver enzymes, which worsened after the administration of high-dose steroids. Despite intravenous normal saline resuscitation, serum transaminitis persisted in a fluctuating manner. Ultimately, a liver biopsy confirmed GH. Biochemically, GH is driven by high amounts of both circulating glucose and insulin or by the administration of high-dose steroids. Improving glycemic control is the mainstay of treatment for GH. However, in our case, improvement in glycated hemoglobin of just 0.6% was enough to achieve symptomatic relief, supporting recent claims of the involvement of other identified factors in disease development.

Verrucous carcinoma of the esophagus: A potential diagnostic dilemma

Verrucous carcinoma of the esophagus is a rare variant of squamous cell carcinoma associated with human papillomavirus. We report the case of a 58-year-old female who presented with ongoing symptoms of dysphagia. On previous endoscopies she had been noted to have a large polyp-like mass involving the esophagus, with negative biopsies for malignancy. Repeat endoscopy with concurrent endoscopic ultrasound showed a large semi-pedunculated polyp in the distal esophagus and a hypoechoic, irregular mass involving the gastroesophageal junction with esophageal thickening. Deep layer biopsies showed pseudoepitheliomatous hyperplasia with immunohistochemical staining positive for human papillomavirus. The patient was subsequently treated with chemo-radiation followed by esophagectomy.

Hepatoid Esophageal Carcinoma: a Rare Cause of Elevated Alfa Fetoprotein

AFP-producing tumors are uncommon. They have mostly been described of pulmonary origin. However, they have also been described from gastrointestinal tract. Esophageal involvement with hepatoid tumor has been rarely described. The diagnosis is clinically challenging in patients with metastatic disease to liver. We present an interesting case of AFP-producing esophageal tumor, describing its clinical presentation, endoscopic manifestation, as well as histological features.

Diagnostic Differentiation of Pancreatic Neuroendocrine Tumor From Other Neoplastic Solid Pancreatic Lesions During Endoscopic Ultrasound-Guided Fine-Needle Aspiration.

Objectives To identify factors differentiating pancreatic neuroendocrine tumors (PNETs) from non-PNET neoplastic solid pancreatic lesions (SPLs) and assess the accuracy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). Methods This is a retrospective study at a tertiary center of consecutive patients referred for EUS from 2004 to 2011. The main outcomes were pretest predictors and accuracy of EUS-FNA for diagnosis of PNET. Results Among a total of 1108 EUS-FNAs for pancreatic lesions, 672 patients (PNET = 91, non-PNET neoplastic-SPLs = 581) had neoplastic-SPLs. The sensitivity, specificity, and accuracy of EUS-FNA for diagnosis of PNETs were 98.9%, 100%, and 99.9%, respectively. The mean needle-passes were 3.0/patient. The EUS volume (mean/year per endosonographer) in preceding 3 years significantly correlated with fewer needle passes (rs: [−0.26]; P = 0.02). Multivariate analysis demonstrated that patients with PNET when compared to non-PNET neoplastic-SPLs were younger (odds ratio [OR], 3.23; 95% confidence interval [95% CI], 1.19–9.09; P = 0.001), have 2 or more pancreatic lesions (OR, 5.63; 95% CI, 1.74–18.2; P = 0.005), and lower CA 19-9 values (OR, 10.0; 95% CI, 3.13–33.3; P = 0.001). Further, PNETs were less likely to have weight loss (OR, 0.40; 95% CI, 0.17–0.90; P = 0.03), current smoking (OR, 0.47; 95% CI, 0.22–0.98; P < 0.05), pancreatic ductal dilation (OR, 0.28; 95% CI, 0.13–0.60; P = 0.002), or imaging evidence of arterial invasion (OR, 0.22; 95% CI, 0.07–0.71; P = 0.01). Conclusions Although pre-FNA findings can reliably characterize, EUS-FNA is highly accurate for the diagnosis of PNETs.

Clinical decision making in the management of pancreatic cystic neoplasms

Pancreatic cystic lesions continue to pose diagnostic and management dilemmas for physicians. This may be related, in part, to the fact that these lesions represent a range of diagnostic possibilities, from inflammatory cysts and nonmucinous cysts to mucinous cysts, which may or may not have foci of invasive malignancy. Adequate characterization of cystic lesions is necessary to help devise a management plan. Moreover, patient-related factors such as comorbid conditions are often essential in deciding whether patients should be managed by a conservative approach of watchful waiting versus surgical resection, if so indicated. This review summarizes the recent advances in the management of pancreatic cystic neoplasms.

First report of celiac plexus block for refractory abdominal pain secondary to peripancreatic colon cancer metastasis

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Hemobilia after Percutaneous Liver Biopsy Presenting as Hematochezia: A Rare Complication of a Commonly Performed Procedure

Background: Hemobilia is defined as hemorrhage into the biliary tract. With frequent use of invasive hepatobiliary procedures in current gastroenterology practice and promptly advancing imaging and endoscopic techniques, this disease process is increasingly being diagnosed. Clinically, this condition often presents as a classic triad of biliary colic, jaundice and upper gastrointestinal bleed (manifesting as hematemesis or melena). Case Report: A 35-year-old white woman with recent liver biopsy presented to the emergency department with 1 week’s history of right upper quadrant abdominal pain, nausea, vomiting, and multiple episodes of bleeding per rectum. X-ray abdomen and CT scan were unremarkable. Esophagogastroduodenoscopy was performed which showed ongoing blood flow through the ampulla of Vater. Diagnosis of hemobilia was made. Angiographic embolization of the segmental hepatic artery was done with resolution of bleeding. Conclusion: To conclude, hemobilia is a rare cause of upper gastrointestinal bleed. Trauma, predominantly iatrogenic and occasionally accidental, is the most common cause for this disease entity. Bleeding in these cases manifests predominantly as hematemesis or melena. In rare cases, as in our patient, bleeding may present as hematochezia. Diagnosis is predominantly made on upper gastrointestinal endoscopy. Angiographic embolization remains the cornerstone of management.

Idiopathic esophageal ulcers after autologous hemopoetic stem cell transplant: Possible role of IgA levels

Dear Editor, Idiopathic esophageal ulcers have been well described in immunocompromised individuals with acquired immunodeficiency syndrome [1–3]. There has been recent description of this disease in organ transplant recipients [4–6]. It is unknown if this is a consequence of immunosuppression or occurs as a result of host response to transplantation. We herein describe a case of autologous hemopoetic stem cell transplant recipient with idiopathic esophageal ulcers. To our knowledge, there has been no previous description of this entity in autologous hemopoetic stem cell transplant patients. A 55-year-old white gentleman with IgG kappa light chain multiple myeloma treated with autologous hemopoetic stem transplant was evaluated for complains of recent onset, gradually progressive dysphagia and odynophagia over a period of 2 weeks. Symptoms ensued within 4 weeks of the stem cell transplant and continued despite adequate acid suppression with proton pump inhibitor therapy and empiric antifungal and antiviral therapy with liposomal amphotericin-B and gancyclovir respectively. No history of nausea, vomiting, hemetemesis or melena was reported. The patient received high dose chemotherapy with melphalan 300 mg/m2 BSA, bortezomib (Velcade), thalidomide and dexamethasone followed by stem cell transplant in June, 2007. The dose of melphalan was higher than usual given high-risk disease features (cytogenetics and gene array profile) and the fact that the patient had relapsed after a total therapy of three regimens (two induction cycles followed by tandem transplants with melphalan 200 mg/m in 2005). Given history of CMV reactivation in past (PCR testing at that time being negative) and also given history of candidemia in past, patient was continued on ganciclovir and liposomal amphotericin-B therapy. However symptoms were persistent and later these were discontinued. Esophageoduodenoscopy revealed multiple ulcers in the mid esophagus within 30 cm of the gastroesophageal junction. Multiple biopsies were taken from the margins of the ulcers. Pathologic evaluation of the biopsy specimens indicated acute ulcerative esophagitis. Gomori methamine silver (GMS) stain and periodic acid Schiff (PAS) stain for fungal organisms was found to be negative. Immunohistochemical stains for cytomegalovirus (CMV) and herpes simplex virus (HSV) were also found to be negative. No evidence of neoplastic process was found. Histopathologic evaluation of random gastric biopsy specimens revealed mild gastritis with no evidence of Helicobacter pylori infection. All specimens were found to be negative for presence of amyloid deposition. In light of the clinical presentation, endoscopic evaluation and histopathologic findings, a diagnosis of idiopathic esophageal ulcers was made. Therapy with a proton pump inhibitor (pantoprazole 40 mg twice daily) and oral sucralfate was initiated with gradual and complete resolution of symptoms. These were started 1 month after Ann Hematol (2008) 87:1031–1032 DOI 10.1007/s00277-008-0533-5