Nayana George

Endoscopic ultrasound fine needle aspiration: Technique and applications in clinical practice

Since its initial report in 1992, endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has now been incorporated into the diagnostic and staging algorithm for the evaluation of benign and malignant diseases of the gastrointestinal tract and of adjacent organs. Its introduction constitutes a major breakthrough in the endoscopic field and has gradually transformed EUS from a pure imaging modality into a more interventional procedure. In addition, the possibility of collecting samples, providing a definitive cytological and/or histological evidence of the presence of malignancy, has strongly contributed to changing EUS from a subjective, highly operator dependant procedure into a more objective one. This article will review the instrumentation, technique and the most important clinical applications of EUS-FNA.

What is the current role of endoscopy in primary sclerosing cholangitis

Endoscopy has important roles in the management of primary sclerosing cholangitis (PSC), ranging from narrowing down the differential diagnoses, screening for complications, determining prognosis and therapy. While the need for a diagnostic endoscopic retrograde cholangiopancreatography (ERCP) may be obviated by a positive magnetic resonance cholangiopancreatography (MRCP), a negative MRCP does not exclude PSC and may therefore necessitate an ERCP, which is traditionally regarded as the gold standard. In this editorial we have not covered the endoscopic management of inflammatory bowel disease in the context of PSC nor of endoscopic surveillance and treatment of portal hypertension complicating PSC.

Interplay of gender, age and drug properties on reporting frequency of drug-induced liver injury

ABSTRACT We examined the effect of gender, age, and drug properties on liver events reporting frequency (RF) to assess patient‐ and drug‐related risks for drug‐induced liver injury (DILI). We performed a data‐mining analysis of the WHO VigiBase™ to 1) identify drugs with gender‐ and age‐biased RF and 2) characterize drug properties using the Liver Toxicity Knowledge Base. Age‐, gender‐specific Empirical Bayes Geometric Mean of relative reporting ratio of liver events with 90% confidence interval (CI) was calculated for 375 drugs with DILI potential. Forty‐one drugs showed an increased RF in women, which had a higher prevalence of reactive metabolite formation and mitochondrial dysfunction and transporter inhibition. Fifty‐nine drugs showed an increased RF in younger women (<50 yrs), many of which had a signature pattern of hepatocellular injury. In contrast, half of 17 drugs that showed an increased RF in men had a cholestatic pattern. In the older group (≥50 yrs), 17 drugs showed an increased RF and had higher transporter inhibition, Cmax, and plasma protein binding, yet shorter plasma elimination. Specific drug properties were associated with gender‐ and age‐biased liver events RF, suggesting possible interactions of drug properties, gender, and age in DILI development. HighlightsAge/gender‐based liver events reporting frequencies (RF) were assessed.Drugs with age/gender‐biased RF showed specific properties and injury patterns.Identified properties aid in studying drug‐host interactions in liver events. Abbreviations: DILI: drug‐induced liver injury; DILIN: drug‐induced liver injury network; HC: hepatocellular; CS/MIX: cholestatic/mixed; ALT: alanine aminotransferase; ALP: alkaline phosphatase; ULN: upper limit normal; ANA: antinuclear antibody; OR: odds ratio; CI: confidence interval; RF: reporting frequency; WHO: World Health Organization; LTKB: Liver Toxicity Knowledge Base; Cmax: maximum/peak drug concentration; T1/2: half life; MRP 2,3,4: multidrug resistance associated protein 2, 3 4; MedDRA: Medical Dictionary for Regulatory Activity; RRR: relative reporting ratio; EBGM: Empirical Bayes Geometric Mean of relative reporting ratio of liver events; FDA: food and drug administration; BDDCS: Biopharmaceutics Drug Disposition Classification System; ATP: Adenosine triphosphate; CYP: cytochrome.

Ectopic Hepatocellular Carcinoma within a Choledochal Cyst Diagnosed Using Single-Operator Digital Cholangioscopy

Ectopic Hepatocellular Carcinoma within a Choledochal Cyst Diagnosed Using Single-Operator Digital Cholangioscopy

Colorectal cancer screening use among insured adults: Is out-of-pocket cost a barrier to routine screening?

AIM To describe the characteristics of adults who needed to see a doctor in the past year but could not due to the extra cost and assess the impact of limited financial resources on the receipt of routine fecal occult blood test, sigmoidoscopy, or colonoscopy for colon cancer screening among insured patients. METHODS Data obtained from the 2012 Behavioral Risk Factor Surveillance System included 215436 insured adults age 50-75 years. We computed frequencies, adjusted odds ratios (aORs), and 95%CIs using SAS v9.3 software. RESULTS Nine percent of the study population needed to see a doctor in the past year but could not because of cost. The numbers were significantly higher among those aged 50-64 (P < 0.0001), Non-Hispanic Whites (P < 0.0001), and those with a primary care physician (P < 0.0001) among other factors. Adjusting for possible confounders, aORs for not seeing the doctor in the past year because of cost were: stool occult blood test within last year aOR = 0.88; 95%CI: 0.76-1.02, sigmoidoscopy within last year aOR = 0.72; 95%CI: 0.48-1.07, colonoscopy within the last year aOR = 0.91; 95%CI: 0.81-1.02. CONCLUSION We found that the limited financial resources within the past 12 mo were significantly associated with colorectal cancer (CRC) non-screening. Patients with risk factors identified in this study should adhere to CRC guidelines and should receive financial help if needed.

Verrucous carcinoma of the esophagus—remains a diagnostic enigma

with no prominent cytological atypia and typical vascular invasion are shown in Fig. 3 (hematoxylin and eosin, magnification ×20 and ×40, respectively). The polyp stalk was free of tumor infiltration. A strict endoscopic and radiological surveillance program was undertaken, based on upper endoscopy and contrast-enhanced CT scan performed at month 3 and 6 after polypectomy. No evidence of recurrent HCC was reported after one year, including also a positive emission computed tomography. Fatigue and anemia progressively improved after endoscopic polyp resection, with return to normal hemoglobin levels within six months. HCC extension to small bowel is considered anecdotal and generally restricted to patients with diffuse neoplastic involvement of the liver [1, 2]. To our knowledge, only one case has been described of a single duodenal isolated recurrence of HCC [2]. However, this patient was not a liver transplant recipient and had fibrolamellar HCC. HCC recurrence nowadays is reported at a rate lower than 20% after liver transplantation, according to a retrospective radiologic study involving 119 patients [3]. Notably, in the latter study extra-hepatic recurrence of HCC without liver involvement was not a rare event, being observed in 4 of 16 recurrent cases. To our knowledge, this is the first report of a duodenal recurrence of a solitary HCC after liver transplantation. Although this unusual site of extrahepatic tumor recurrence is probably rare, this possibility, together with other more frequent classical sites, such as lymph nodes, lung and adrenal glands, should be taken into consideration in the long-term surveillance of patients liver-transplanted for HCC.

The Utility of Endoscopic Ultrasound–Guided Brachytherapy in Liver Metastasis: A Case Report and Review of the Literature

Endoscopic ultrasound guided brachytherapy (EGBT) has been reported to be useful in certain malignancies including esophageal and pancreatic cancers. Percutaneous or surgical placement of radioactive seeds into the liver secondaries (brachytherapy) has been done successfully, however, the utility of EGBT in liver metastasis remains largely unclear. In this case report, we demonstrate the safety, efficacy and feasibility of EUS guided brachytherapy (EGBT) in liver metastasis secondary to leiomyosarcoma.

Downhill esophageal varices: unusual cause of hematemesis

“Downhill” esophageal varices distributed predominantly in the proximal esophagus are unusual causes of hematemesis, comprising 0.1% of all cases of variceal hemorrhage. They are seen in up to 30% of cases of superior vena cava (SVC) obstruction from benign and malignant causes. The pathophysiology of their formation and management is different from that of the more usual “uphill” varices commonly seen that result from portal hypertension. These varices are caused by the formation of collaterals caused by obstruction of the superior vena cava. Their distribution in the esophagus varies relative to the level of SVC obstruction with the azygos vein. Patients with end-stage renal disease (ESRD) who are receiving long-term dialysis are particularly at risk for SVC obstruction/stenosis from the sustained use of indwelling

Metastatic duodenal germ cell tumor diagnosed with endoscopic ultrasound

Testicular tumors are the most common solid tumors reported in young males aged 15–35 years [1, 2]. These tumors frequently metastasize to retroperitoneal lymph nodes, but only 5% of these tumors seed the gastrointestinal (GI) tract [3, 4], with the duodenum being the least common site (1.4%) [4]. Local extension from the retroperitoneal lymph node into the GI tract is the common method of spread. We report on a 44-year-old man with symptoms of gastric outlet obstruction. Computed tomography (CT) of the abdomen showed a bilobed retroperitoneal mass of 7×5 cm compressing the duodenum, suspicious for duplication cyst (▶Fig. 1a, b). Esophagogastroduodenoscopy showed a subepithelial nearobstructive mass in the second portion of the duodenum, which appeared cystic on palpation with closed forceps (▶Fig. 1 c). Endoscopic ultrasound (EUS) showed a 7×5.4 cm solid cystic mass (▶Fig. 1d). Fine-needle biopsy (FNB) with a 22-gauge needle (▶Fig. 1 e) revealed poorly differentiated epithelioid carcinoma, with unknown primary. Given the patient’s age, testicular tumor was a highly likely differential diagnosis. The patient underwent pancreas-sparing duodenal resection. Histology showed a mixed germ cell tumor with unusual presence of cartilage (▶Fig. 1 f). Ultrasound of the testes showed a 1.7 cm E-Videos

Endoscopic Dissolution of Gastric Lipoma with Argon Plasma Coagulation

A 47-year-old patient presented from outside the hospital for evaluation of iron deficiency anemia (IDA). The endoscopic workup suggested a gastric antral subepithelial lesion with an overlying arteriovenous malformation (AVM). Endoscopic ultrasound (EUS) revealed the lesion to be a lipoma. Given the patient’s anemia and blood transfusion requirements, the AVM was treated with argon plasma coagulation (APC). During this treatment, desiccation of fat was noted with a significant decrease in the size of the subepithelial lesion (the gastric lipoma). While the APC therapy was intended for management of the overlying AVM, it resulted in the partial dissolution of the gastric lipoma, proving to be a potential diagnostic and therapeutic tool.