Rohan Mandaliya

Spiral Enteroscopy Utilizing Capsule Location Index for Achieving High Diagnostic and Therapeutic Yield

Background and Aim. Spiral enteroscopy (SE) is a new small bowel endoscopic technique. Our aim is to review the diagnostic and therapeutic yield, safety of SE, and the predictive role of prior capsule endoscopy (CE) at an academic center. Methods. A retrospective review of patients undergoing SE after prior CE between 2008 and 2013 was performed. Capsule location index (CLI) was defined as the fraction of total small bowel transit time when the lesion was seen on CE. Results. A total of 174 SEs were performed: antegrade (147) and retrograde (27). Abnormalities on SE were detected in 65% patients. The procedure was safe in patients with surgically altered bowel anatomy (n = 12). The diagnostic yield of antegrade SE decreased with increasing CLI range. The diagnostic yield of retrograde SE decreased on decreasing CLI range. A CLI cutoff of 0.6 was derived that determined the initial route of SE. Vascular ectasias seen on CE were detected in 83% cases on SE; p < 0.01. Conclusions. SE is safe with a high diagnostic and therapeutic yield. CLI is predictive of the success of SE and determines the best route of SE. The type of small bowel pathology targeted by SE may affect its utility and yield.

Association between common variable immunodeficiency and collagenous infiltrative disorders of the gastrointestinal tract: A series of four patients

Hypogammaglobulinemia/common variable immunodeficiency (CVID) may lead to disruption of the gut mucosal immune barrier. Collagenous infiltrative disorders of the intestinal tract (colitis, gastritis, sprue) constitute a relatively new spectrum of gastrointestinal disorders. Our aims were (1) to determine the association between immunoglobulin deficiency state like CVID and collagenous infiltrative disorders of the gut and (2) to study the clinic-pathologic characteristics and treatment outcomes in these patients. A retrospective search was conducted to identify cases with concurrence of these two conditions at an academic center from 2007 to 2013. Four such patients were identified from our database: three with collagenous colitis and one with collagenous gastritis. All patients with collagenous colitis had normal colonic mucosa while the patient with collagenous gastritis had nodular gastric mucosa. Only one patient out of four had decreased plasma cells in the submucosa as expected in low immunoglobulin states. All patients had improvement in their symptoms on immunoglobulin therapy with considerable remission on budesonide. Literature search revealed reporting of four similar patients. In conclusion, (1) the association between collagenous infiltrative disorders of the gut and CVID and its prompt response to immunoglobulins with effective maintenance with budesonide are novel findings. Our study also shows that the presence of plasma cells should not rule out the possibility of CVID. (2) In patients with chronic diarrhea, hypogammaglobulinemia and collagenous colitis/sprue should be considered for the available effective treatments such as immunoglobulins and budesonide.

Monitoring inflammatory bowel disease during pregnancy: Current literature and future challenges

Inflammatory bowel disease has a high prevalence in women of childbearing age and can have a significant impact on pregnancy, from conceiving to carrying the pregnancy. Active disease during pregnancy is known to have negative effects on pregnancy outcomes; therefore, careful monitoring during this period is an important but challenging aspect of care and is crucial as it affects important management decisions. Recent data seems to suggest that endoscopy is a relatively safe procedure during all trimesters of pregnancy. Serum biomarkers such as C-reactive protein and fecal calprotectin are helpful non-invasive markers, but have shown conflicting results for correlation with disease activity in some initial studies. Further work is necessary to establish standard of care monitoring during pregnancy.

Tu1001 - Significant Variation in the Detection Rates of Proximal Serrated Polyps Among Academic Gastroenterologists, Community Gastroenterologists and Colorectal Surgeons in a Single Tertiary Care Center

Introduction Recent studies have demonstrated that the protective effect of colonoscopy against colorectal cancer is lower in the proximal colon. Proximal serrated polyps, including sessile serrated adenomas and proximal hyperplastic polyps, can be frequently missed and pose a risk of interval cancers.

Gastroparesis Concurrent with Adult Cystic Fibrosis; Are They Related?

The recent recognition of cystic fibrosis in an adult patient with severe gastroparesis led us to further investigate this novel association. Cystic fibrosis in adults is being diagnosed more often with the advent of genetic mutation analysis. Gastrointestinal manifestations are the most important nonpulmonary manifestations of cystic fibrosis that contribute to the reduced survival of these patients. Some of the gastrointestinal motility disorders associated with cystic fibrosis include gastroesophageal reflux disease, distal intestinal obstruction syndrome, and constipation. However, gastroparesis from cystic fibrosis diagnosed in adults has not been reported. A 60-year-old white woman presented with a 1-year history of postprandial fullness, bloating, abdominal pain, vomiting, and early satiety. Gastric scintigraphy emptying scan demonstrated T 1/2 (half time of gastric emptying) >140 minutes, consistent with the diagnosis of severe gastroparesis. She did not have diabetes, central nervous system disease, or history of abdominal surgery, and was not taking any medications that can slow gastric emptying. Her symptoms were only partially relieved with metoclopramide, botulinum toxin injections to pylorus, and consuming smaller meals. She was having recurrent respiratory infections with evidence of bronchiectasis on imaging. She underwent a partial lobectomy for the treatment of her bronchiectasis. Because of persistent symptoms, she sought consultation at a tertiary lung center. She was then evaluated for cystic fibrosis (6 years after the diagnosis of bronchiectasis). She had a positive sweat chloride test (64 mmol/L). Genetic analysis revealed 2 mutations: DF508 (most common) and 711 3G->A, consistent with a diagnosis of cystic fibrosis. The patient currently requires intermittent course of antibiotics for pulmonary infections. Her symptoms of gastroparesis are not well controlled.

A Challenging Case of Splenomegaly and Refractory Thrombocytopenia

DIS 5.4.0 DTD YGAST59932 proof 27 January 2016 11:24 pm ce Gastroe 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 Question: A 59-yearold man presented with a 2-week history of left-sided dull abdominal pain. He denied having diarrhea, fever, or weight loss. Physical examination revealed an enlarged spleen 3 cm below the costal margin. Complete blood count revealed isolated thrombocytopenia (platelets 40 10/L) with no 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 other coagulation or metabolic abnormalities. Abdominal ultrasonography showed splenomegaly with a normal liver. Contrast-enhanced computed tomography of the chest and abdomen revealed low-density masses in the spleen with marked splenomegaly measuring 22 cm craniocaudally (Figure A, B). Serologies for viral infections (human immunodeficiency virus, Epstein–Barr virus, hepatitis C virus) and autoimmune diseases were negative. Bone marrow biopsy showed a normocellular marrow with increased megakaryocytes. There was no evidence of leukemia or lymphoma. The etiology of thrombocytopenia was unclear at this point. Primary immune thrombocytopenia was unlikely in the presence of splenomegaly and hypersplenism could not explain this degree of thrombocytopenia. Splenic lymphoma was considered in the differential diagnosis and he was started on prednisone for presumed malignancy-related immune thrombocytopenia. No benefit was noted. Splenectomy had to be deferred as platelet counts were persistently between 10 and 20 10/L. He continued to remain thrombocytopenic despite receiving intravenous immunoglobulins, 3 cycles of rituximab, and multiple platelet transfusions. What is the diagnosis in this patient with splenomegaly, hypodense lesions in the spleen, and severe, refractory thrombocytopenia? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. 102 103 104 105 106 107 108 Conflicts of interest The authors disclose no conflicts.

Small Cell Lung Cancer Presenting as Severe Thrombocytopenia and Refractory Hypokalemia

A 70-year-old female with a history of mild cirrhosis was referred by her primary care provider for a platelet count of 36,000/μL which had dropped from 47,000/μL in a week along with mild pain in extremities. Serum potassium was low (2.9 mEq/L) in spite of the patient being recently started on potassium supplement on outpatient for hypokalemia. Initially thrombocytopenia was attributed to cirrhosis. However, platelet counts continued to drop to a nadir of 9000/μL in spite of several platelet transfusions. Hypokalemia was refractory to potassium supplements. Subsequent bone marrow biopsy revealed extensive marrow necrosis with a focus of small cell tumor cells of pulmonary origin. CT scan of the chest showed a spiculated left lung mass. The ACTH level was high, with normal rennin and aldosterone levels. The patient likely had ectopic ACTH syndrome from small cell lung cancer. She died within few days of diagnosis. Severe thrombocytopenia and refractory hypokalemia can rarely be initial presentations of small cell lung cancer. Thrombocytopenia should prompt an evaluation for bone marrow metastases and a search for undiagnosed systemic malignancy. In severe cases of metastases, bone marrow necrosis can be present. Refractory hypokalemia can be the sole presentation of ectopic ACTH production.