R. Grassia

Antibiotic treatment of small bowel bacterial overgrowth in patients with Crohn's disease

Background : Small bowel bacterial overgrowth is common in Crohns disease but its treatment is not clearly defined. Metronidazole and ciprofloxacin are effective antibiotics in active Crohns disease.

Bowel sonography for the diagnosis and grading of postsurgical recurrence of Crohn's disease.

Background and Aims: Postsurgical recurrence (PSR) is common in patients with Crohns disease (CD) who have undergone surgery. Endoscopy is crucial for the diagnosis of PSR, showing also high prognostic value. Bowel sonography (BS) is accurate for CD diagnosis, but its role in PSR detection and grading has been poorly investigated. The aim of this study was to evaluate the diagnostic accuracy of BS compared to endoscopy in the detection of PSR. Materials and Methods: Between March 2002 and October 2005, to gain evidence of possible PSR, we prospectively performed endoscopy and BS in 45 CD patients who had undergone previous bowel resection. Endoscopy and BS were carried out 1 year after surgery, with diagnosis and grading of PSR made in accordance with Rutgeerts. BS was considered suggestive for PSR in the presence of bowel wall thickness (BWT) >3 mm. Also, an ROC curve was constructed to define the best cutoff value for BWT to differentiate mild from severe PSR (grade 1–2 vs 3–4 of Rutgeerts). Results: Of the 45 patients with CD, 24 showed endoscopic evidence of PSR (53%). Severe endoscopic PSR was present in 16 patients (66%). Sensitivity, specificity, and positive and negative predictive values of BS were 79%, 95%, 95%, and 80%, respectively, with a sensitivity of 93% for severe PSR. On the ROC curve, a BWT >5 mm showed sensitivity, specificity, and positive and negative predictive values of 94%, 100%, 100%, and 96%, respectively, in differentiating mild from severe PSR, in remarkable agreement with endoscopy (&kgr; = 0.90). Conclusions: BS shows good sensitivity and high specificity for the diagnosis of PSR in CD, with a BWT >5 mm being strongly indicative of severe endoscopic PSR. Hence, BS could replace endoscopy for the diagnosis and grading of PSR in patients who comply poorly with the endoscopic examination.

Endoscopic “retroperitoneal fatpexy” of a large ERCP-related jejunal perforation by using a new over–the-scope clip device in Billroth II anatomy (with video)

www.giejournal.org Vo ng about 20 mm was visualized distal to the papilla Fig. 1A). The patient was inoperable because of adanced age and comorbidities, so we tried endoscopic epair of the perforation. The guidewire was left in the ile duct, and a partially covered self-expandable metal tent was placed through the stricture. Because the hole as too large, we decided to close the perforation with n over–the-scope clip (OTSC) device (12-mm OTSC astric closure; Ovesco Endoscopy, Tubingen, Gerany) by using a standard gastroscope with a distal ttachment. The patient gave informed consent before he endoscopic procedure. We used the OTSC twin rasper. The twin grasper has 2 independently movable aws that were pushed out to grasp the wound edges nd firmly pull tissue margins inside the cap. Suction as used to draw retroperitoneal fat into the defect into he OTSC applicator cap. After the damaged tissue was ully pulled into the cap, a “retroperitoneal fat patch” as made obtaining complete closure of the perforation t the clip deployment (Fig. 1B, Video 1, available nline at www.giejournal.org). An abdominal CT with astrographin showed a pneumoretroperitoneum in the eripancreatic perirenal area and no fluid collections Fig. 2). Peripheral parenteral nutrition and intravenous igure 2. CT performed after the closure of the perforation with the ver-the-scope clip (large arrow) showing the presence of a pneumoretoperitoneum in the peripancreatic right area, right colic flexure (small rrow), and no evidence of leaks.

Abdominal wall pseudocyst fluid collection: the unexpected presentation of pancreatic pseudocyst

A 65-year-old woman presented with abdominal pain, nausea, and hyporexia lasting 2 weeks. The symptoms were associated with alimentary vomiting and intestinal obstruction. The patient denied any previous episodes similar to this presentation. Her past medical history was unremarkable except for psychiatric disorder. Physical examination on admission revealed a large palpable mass in the epigastrium with associated tenderness but no signs of peritonitis. The patient was afebrile, tachycardic and normotensive. The laboratory findings showed increased C-reactive protein (143 mg/L), slight elevated levels of alanine transaminase (68 IU/L), aspartate aminotransferase (48 IU/L), G-glutamyl transpeptidase (96 IU/L). The serum bilirubin level, amylase and lipase were normal. The blood count showed hemoglobin at 12.5 g/dL, white blood cells at 8.80 g/L, and platelets at 285 g/L. The tumor markers were also in normal range (carcinoembryonic antigen, 1.3 ng/mL; carbohydrate antigen 19-9, 28.7 U/mL). A plain film of the abdomen was unremarkable. Abdominal ultrasound examination exhibited a voluminous swelling of approximately 13 × 5 cm diameter, dishomogeneously hypoechoic, in the epigastric region. The computed tomography with contrast enhancement confirmed the large 13.5-cm hypodense mass in the sub-diaphragmatic space, close to the anterior abdominal wall, reaching the stomach behind, without clear signs of infiltration, but with widespread thickening of the adipose tissue and some small adenopathies in the context (Fig. 1a–c). The left branch of portal vein was sharply thinned. A necrotic and partially colliquated mesenchymal tumor was initially suspected, and the patient underwent exploratory surgical laparotomy. The patient underwent exploratory surgical laparotomy and aspiration drainage of a necrotic cystic-purulent collection (Fig. 1d, e). The fluid was straw-colored and turbid in appearance. Fluid was sent for biochemical analysis, cytology, and microbiology culture. The amylase level in the fluid was 1331 U/L, and lipase was 254 U/L. Cytology showed no evidence of malignant cells. Microbiology showed culture of Streptococcus anginosus. Pancreatic pseudocyst can be seen as a complication of acute pancreatitis, and, more often in chronic pancreatitis. The most probable etiology is related to alcoholic chronic pancreatitis. However, in this case, neither anamnestic reference was known in relation to alcohol abuse nor previous pancreatic inflammatory events. Pancreatic pseudocysts form after the disruption of the pancreas parenchyma and ductal system. This releases pancreatic enzymes, which, in turn, can digest adjoining tissues. This process produces a collection of enzymes, hemolyzed blood, and necrotic debris lined by granulation tissue. Pseudocysts can be classified into intrapancreatic and extrapancreatic. Extrapancreatic pseudocysts occur in the lesser sac (39%), in the anterior pararenal space (31%), within the substance of the liver (10%), in the spleen (6%), and in the mediastinum (2%). Extrapancreatic fluid collections are notorious for crossing fascial boundaries, and can be found in all retroperitoneal compartments [1]. In this case, the inflammatory processes seemed to have been delivered to the anterior abdominal wall from the pancreatic head and the hepatoduodenal ligament and along the falciform ligament (Fig. 1f). This is the pathway the pseudocyst tracked to the anterior abdominal wall. Another anatomical route to the tracking of liberated pancreatic enzymes to the anterior abdominal wall could arise from the inflamed gastrohepatic ligament and across the falciform ligament. Another more direct pathway may be * Federico Pasin f.pasin@ospedale.cremona.it; f.pasin@ASST-CREMONA.it

Loss of expression of μ-protocadherin and protocadherin-24 in sporadic and hereditary non polyposis colorectal cancers (HNPCC)

Colorectal cancer (CRC) is a neoplastic disease in which normal mucosa undergoes a process of malignant transformation due to the progressive accumulation of molecular alterations affecting proto-oncogenes and oncosuppressor genes. Some of these modifications exert their carcinogenic potential by promoting a constitutive activation of the β-catenin signaling proliferation pathway, and when present, loss of cadherin expression also significantly contributes to the same effect. Using a combined approach of molecular and immunohistochemical analysis, we have previously demonstrated that most sporadic CRCs exhibit a down-regulated expression of a cadherin, named μ-protocadherin, that is generally observed in association with a higher proliferation rate and a worse prognosis. The aim of this report was to perform a comparative immunohistochemical assessment of μ-protocadherin and a similar cadherin, named protocadherin-24, in sporadic CRC and hereditary nonpolyposis colorectal cancer. The data obtained put in evidence that double-negative CRCs, lacking both the analyzed protocadherins, are more represented among sporadic tumors, whereas double-positive CRCs, maintaining their expression, exhibit an opposite trend. As expected, loss of protocadherin expression was accompanied by nuclear localization of β-catenin and increased positivity of the Ki-67 proliferation marker. This finding is consistent with the different clinical evolution of the 2 considered CRC sets according to which patients with hereditary nonpolyposis colorectal cancer experience a better prognosis as compared with those affected by a sporadic CRC.

Crohn’s disease and acquired von Willebrand syndrome: a rare dangerous affair?

Dear Sir,Acquired von Willebrand syndrome (AVWS) is a rare bleeding disorder, with variable pathogenesis, similar to inherited von Willebrand disease in term of laboratory findings and clinical sev...

Non-variceal upper gastrointestinal bleeding: Rescue treatment with a modified cyanoacrylate

AIM To evaluate the safety and efficacy of a modified cyanoacrylate [N-butyl-2-cyanoacrylate associated with methacryloxysulfolane (NBCA + MS)] to treat non-variceal upper gastrointestinal bleeding (NV-UGIB). METHODS In our retrospective study we took into account 579 out of 1177 patients receiving endoscopic treatment for NV-UGIB admitted to our institution from 2008 to 2015; the remaining 598 patients were treated with other treatments. Initial hemostasis was not achieved in 45 of 579 patients; early rebleeding occurred in 12 of 579 patients. Thirty-three patients were treated with modified cyanoacrylate: 27 patients had duodenal, gastric or anastomotic ulcers, 3 had post-mucosectomy bleeding, 2 had Dieulafoy’s lesions, and 1 had duodenal diverticular bleeding. RESULTS Of the 45 patients treated endoscopically without initial hemostasis or with early rebleeding, 33 (76.7%) were treated with modified cyanoacrylate glue, 16 (37.2%) underwent surgery, and 3 (7.0%) were treated with selective transarterial embolization. The mean age of patients treated with NBCA + MS (23 males and 10 females) was 74.5 years. Modified cyanoacrylate was used in 24 patients during the first endoscopy and in 9 patients experiencing rebleeding. Overall, hemostasis was achieved in 26 of 33 patients (78.8%): 19 out of 24 (79.2%) during the first endoscopy and in 7 out of 9 (77.8%) among early rebleeders. Two patients (22.2%) not responding to cyanoacrylate treatment were treated with surgery or transarterial embolization. One patient had early rebleeding after treatment with cyanoacrylate. No late rebleeding during the follow-up or complications related to the glue injection were recorded. CONCLUSION Modified cyanoacrylate solved definitively NV-UGIB after failure of conventional treatment. Some reported life-threatening adverse events with other formulations, advise to use it as last option.

Modified dose-dense taxotere cisplatin fluorouracil regimen (mTCF-dd) in a large cohort of patients (pts) with metastatic or locally advanced non-squamous gastroesophageal cancer (GEC).

e15552Background: TCF is one of the most effective first-line option in metastatic GEC. We previously reported on the promising and high activity of mTCF-dd (Tomasello G et al: Gastric Cancer 2014 ...

Jejunal volvulus: an exceptional PEG adverse event

A 50-year-old man with amyotrophic lateral sclerosis was admitted to the intensive care unit because of acute respiratory failure and worsening dysphagia. Because of these considerations, an endoscopic percutaneous gastrostomy (PEG) was performed during the hospitalization. Two days after the beginning of enteral nutrition, the patient experienced symptoms of intestinal subocclusion (nausea and vomiting, recurrent abdominal pain, abdominal distension, and constipation) without signs of peritonitis; a clear bowel hyperperistalsis was evident at auscultation. Blood tests showed normal results except for a mild neutrophilic leukocytosis (white blood cell count 11.900; N 81%). The bowel symptoms did not improve after the use of prokinetic agents or by the reduction of the total volume of enteral nutrition. As a consequence, a diagnostic workup was performed. A radiograph showed air distension of

An Unusual Storm Within the Gastroduodenal Tract

Question: A 53-year-old man with a medical history of heavy smoking, alcohol intake, hypertension, and diabetes was admitted for acute epigastric pain and dyspnea occurred while walking. His past medical history was negative for cardiac and gastrointestinal diseases. At initial evaluation he had high-grade fever without chills, intense asthenia, and alimentary vomiting. On physical examination, he was found to have mild epigastric tenderness; the blood pressure was elevated (190/100 mm Hg) and the glucose test was 326 mg/dL. Complete cardiac evaluation, and renal and hepatic tests were unremarkable; others laboratory examinations showed leukocytosis (white blood cell count, 22,830 mm), increased CRP (293 mg/L), normal hemoglobin, and slightly decreased platelets count (134,000 mm); urine and blood cultures were negative; antinuclear antibody and creatine phosphokinase were normal. To assess vascular disease, he underwent contrast-enhanced computed tomography of the chest and abdomen that excluded pulmonary embolism but showed plaques in the thoracic aorta, thickening of gastric wall with collateral circulation (Figure A). Subsequently, the upper gastrointestinal endoscopy revealed thickening of fundal folds and hyperemic gastric mucosa with numerous ulcerations up to 15 mm in diameter covered by fibrin both in the gastric and duodenal mucosa (Figure B, C). Biopsies were obtained from the gastric and duodenal portion. He was started on proton pump inhibitor therapy, antipyretic drugs, and an enhanced antihypertensive regimen. What is the most likely diagnosis? Look on page 244 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.