Peter Darwin

Treatment of Severe Esophageal Crohn' s Disease with Infliximab

Esophageal ulceration with fistula is an uncommon manifestation of Crohns disease. Typical presentation of symptomatic esophageal Crohns disease may include dysphagia, odynophagia, weight loss, and chest discomfort. We present a patient with severe esophageal and skin involvement of Crohns disease that was progressive despite conventional therapy including prednisone and 6-mercaptopurine. The diagnosis of Crohns was based on the presence of typical clinical, endoscopic, and pathologic findings, including granulomas in the skin ulcer and the absence of infectious etiologies. The patient had a nearly complete resolution of her esophageal disease with a single infusion of infliximab.

Effect of physician training on fluoroscopy time during ERCP.

Our purpose was to compare fluoroscopy time during endoscopic retrograde cholangiopancreatography (ERCP) between endoscopists with different levels of experience. We performed a cross-sectional analysis of 269 consecutive ERCPs at an academic hospital during 1 year. Median fluoroscopy time was significantly longer in more complex cases, such as in therapeutic (406.5 s [IQR, 235.5–685]) compared to diagnostic (202 s [IQR, 141–481]; P = 0.002) procedures. The experience (number of prior ERCPs) of gastroenterology fellows involved in procedures was an independent predictor of shorter fluoroscopy time when controlling for patient and procedure characteristics (P < 0.0001). Median fluoroscopy time was 2.73 min shorter after at least 50 procedures had been performed (P = 0.039). Time for ERCPs involving fellows was not significantly longer than cases by attending physicians alone (P = 0.23). Increased experience is associated with lower radiation exposure during ERCP training. Radiation reduction methods should be prospectively investigated and integrated into training programs.

Predicting Unresectability in Pancreatic Cancer Patients: The Additive Effects of CT and Endoscopic Ultrasound

BackgroundA standardized method for predicting unresectability in pancreatic cancer has not been defined. We propose a system using CT and endoscopic ultrasound (EUS) to assess patients for unresectable pancreatic cancers.MethodsRadiologic and surgical data from 101 patients who underwent exploration/resection for pancreatic cancer were reviewed. Chi-squares were used to identify five factors significantly correlated with unresectability, which were incorporated into a scoring system (one point for each factor).ResultsThe resectability rates were 84, 56, and 10% for patients with scores of 0, 1, and 2, respectively. All four patients with three risk factors for unresectability had unresectable tumors. The most accurate results were achieved in patients evaluated with both CT and EUS.DiscussionThis scoring system stratifies pancreatic cancer patients into three groups: (1) patients with a score of zero (likely to undergo successful resection), (2) patients with a score of one (likely to benefit from laparoscopic staging prior to attempting resection), and (3) patients with a score of two or higher (low probability of successful resection, who may be better served by neoadjuvant therapy).

Proliferative rate in endoscopic ultrasound fine-needle aspiration of pancreatic endocrine tumors: correlation with clinical behavior.

The objectives of this study were to evaluate the role of endoscopic ultrasonography (EUS)‐guided fine‐needle aspiration (FNA) in the preoperative diagnosis of pancreatic endocrine tumors (PETs) and to investigate whether the Ki‐67 index determined on cytologic material could help predict their behavior.

Metastatic Merkel Cell Carcinoma of the Pancreas Mimicking Primary Pancreatic Endocrine Tumor Diagnosed by Endoscopic Ultrasound-Guided Fine Needle Aspiration Cytology

BACKGROUND Merkel cell carcinoma (MCC) is a relatively infrequent, rapidly progressive and often fatal cutaneous malignancy exhibiting neuroendocrine differentiation. It has a penchant for local recurrence and distant metastasis to various sites, including regional lymph nodes, distant skin, lung, liver, testis and other rare organs, such as the pancreas. There are only 4 cases of MCC metastatic to the pancreas reported in the English-language literature, and they were all diagnosed by histology from pancreatic resection. CASE A 79-year-old woman with a large pancreatic tail mass underwent endoscopic ultrasound guided fine needle aspiration (EUS-FNA). She had a history of MCC of the upper extremity with wide local excision 15 months earlier. Metastatic MCC was diagnosed based on the cytomorphology, characteristic immunohistochemical staining pattern, clinical history and comparison of the morphology with that of the primary tumor. CONCLUSION The cytomorphology and immunohistochemical profile of this neoplasm mimicked a pancreatic endocrine tumor. We discuss the diagnostic pitfalls and differential diagnoses of the metastatic pancreatic MCC, highlighting the importance of thorough clinical history, attention to cytologic detail and corroborating immunohirtochemistry in arriving at the correct diagns. This is the first case ofa metastatic pancreatic MCC diagnosed by EUS-FNA cytology.

Immune Evasion by Helicobacter pylori: Gastric Spiral Bacteria Lack Surface Immunoglobulin Deposition and Reactivity with Homologous Antibodies

Background. Helicobacter pylori infection persists in the presence of potent serum and gastric mucosal anti‐body responses against bacterial antigens. The aim of this article is to report on a study determine whether there is antibody deposition on H. pylori in vivo in the stomach of infected patients and whether gastric and cultured forms of H. pylori differ in their antibody reactivity.

Evaluation of performance of EUS-FNA in preoperative lymph node staging of cancers of esophagus, lung, and pancreas

We reviewed the cytologic and histologic diagnoses and EUS report of 77 consecutive patients who had undergone EUS‐FNA preoperative staging for esophageal, lung, and pancreatic cancers at our institution. A total of 122 EUS‐FNA lymph nodes were identified. Thirty of 77 cases had histologic follow‐up. Using surgical node staging and/or surgical resection as the reference standard, the sensitivity, specificity, accuracy, and positive and negative predictive values were 75%, 95%, 89%, 86%, and 90%, respectively, for EUS‐FNA node staging. We compared cytologically malignant and benign lymph node groups with eight EUS parameters including the total number of lymph nodes found by EUS, the shape, margin, long axis, short axis, echogenicity, location of the lymph node, and EUS tumor staging. We found that the short axis is the best EUS feature to predict malignancy. Lymph nodes found in an abdominal location in esophageal and lung cancer are likely malignant. Diagn. Cytopathol. 2008;36:290–296.

Jackson Pratt drain fluid-to-serum bilirubin concentration ratio for the diagnosis of bile leaks

BACKGROUND Jackson Pratt (JP) drain fluid bilirubin levels may be assayed in the evaluation of possible bile leaks. Although fluid color and bilirubin level may prompt additional evaluation, there are no reference data available. OBJECTIVE To assess the JP drain fluid-to-serum bilirubin ratio in patients with documented bile leaks. DESIGN Prospective case series. SETTING Tertiary referral center. METHODS Patients referred for ERCP for the management of documented bile leaks with a JP drain in place were included. Demographic data, bile leak etiology, and serum bilirubin levels were recorded. JP drain fluid was sent for color evaluation and bilirubin concentration. Control subjects included both patients after nonbiliary surgery with a JP drain in place and medical patients with ascites undergoing paracentesis. RESULTS JP drain fluid-to-serum bilirubin concentration and fluid color evaluation was performed on 23 patients with documented bile leaks by ERCP and compared with 26 controls (16 surgical and 10 medical). The JP drain fluid/ascites-to-serum bilirubin ratio was significantly higher in those with bile leaks (mean ratio 45.6) compared with combined controls (mean ratio 0.9). Use of a cutoff JP drain fluid-to-serum bilirubin ratio of 5 would be 100% sensitive and specific for the prediction of a bile leak in the selected control group. There was overlap in fluid color evaluation between the groups. LIMITATIONS Controls did not include those with suspected bile leaks and negative technetium 99m-HIDA scintigraphy or ERCP findings. CONCLUSIONS JP drain fluid-to-serum bilirubin concentration ratio greater than 5 seems to be highly sensitive and specific for the detection of a bile leak. Used along with clinical criteria, this ratio could be used to select patients to proceed directly to ERCP.

A pilot study of transnasal percutaneous endoscopic gastrostomy.

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Transnasal placement of percutaneous endoscopic gastrostomy with a pediatric endoscope in oropharyngeal obstruction.

dominal ultrasound ruled out gallstone disease. A computed tomography scan confirmed acute pancreatitis with inhomogenous thickening and peripancreatic edema of the pancreatic tail. At ERCP, a focal stricture of the duct of Wirsung was noted in the body of the pancreas (Fig. 1) causing acute pancreatitis in the upstream part of the organ. However, brush cytology was nondiagnostic. Both endosonography and magnetic resonance imaging failed to detect a pancreas mass. Exploratory surgery was both diagnostic and therapeutic in that a distal pancreatectomy with splenectomy had to be performed in the face of the localized pancreatic duct stenosis and splenic vein thrombosis. The differential diagnosis of isolated pancreatic duct strictures includes pancreatic neoplasm, focal chronic pancreatitis, a scar from previous acute pancreatitis and, rarely, ductal fibrosis as a sequela of pancreatic trauma (2, 3). As in our patient, the classic site of pancreatic duct injury lies over the vertebral column in the midportion of the pancreas (3). Pancreatic cancer is the most worrisome culprit and should be considered in all patients in whom a pancreatic duct stricture is identified. Increasingly, neuroendocrine tumors of the pancreas are disclosed as the cause of pancreatic duct stenosis (1, 2). It may be difficult to distinguish malignant from benign disease on the basis of the radiological appearance of an isolated stricture. A focal mass seems to favor malignancy whereas islet cell tumors are frequently tiny and undetectable by sophisticated imaging procedures. Even if evaluation fails to reveal a small pancreatic mass, pancreatic resection remains the treatment of choice (4). Indeed, surgical exploration offers the advantage of both definite tissue diagnosis and symptom relief (5). The role of pancreatic ductal stenting as first-line treatment of benign strictures is still under debate (6). Eighteen months after surgery, the patient remains free of symptoms. On repeat questioning, she eventually remembered a blunt abdominal trauma by a ski pole in a Rocky Mountain ski resort 4 yr before presentation.