Shabnam Sarker

Over-the-scope clip-assisted method for resection of full-thickness submucosal lesions of the gastrointestinal tract.

BACKGROUND AND STUDY AIMS The over-the-scope clip (OTSC; Ovesco Endoscopy, Tübingen, Germany) is deployed after suctioning tissue into the cap. The tissue may then be resected endoscopically. The aim of this study was to evaluate the efficacy and safety of the OTSC for the endoscopic resection of gastrointestinal tumors. PATIENTS AND METHODS This was a retrospective, observational cohort study of patients undergoing endoscopic resection of submucosal lesions. RESULTS Eight patients underwent endoscopic resection of neuroendocrine tumors (NETs) of the duodenum (n = 4), rectum (n = 1), or stomach (n = 2), or granular cell tumor (GCT) of the esophagus (n = 1). The mean size of the lesions was 13.4 mm (range 9 - 20 mm). Application of the clip was successful in all patients. A successful endoscopic resection was accomplished in all. A complete resection (R0) was accomplished in 7/8 patients (87.5 %). A full-thickness resection was achieved in 2/8 (25.0 %), one in a patient with a gastric NET and the other in a patient with GCT of the esophagus. There were no complications. CONCLUSIONS This case series suggests that the OTSC system may be a valuable tool for the resection of submucosal lesions, but further prospective and randomized studies are necessary to assess the indications and outcome.

A new meaning to butterflies in the stomach.

Question: A 68-year-old woman with rheumatoid arthritis maintained on methotrexate presented with a 4-year history of intermittent episodes of abdominal pain and nausea that gradually progressed to emesis and increasing abdominal girth. The symptoms usually lasted for 48-72 hours with resolution of symptoms with food avoidance. Her symptoms initially began after starting methotrexate, which she took orally for 3 years followed by 1 year as a subcutaneous injection. The symptoms were exacerbated after each subsequent weekly dose. Her vital signs, laboratory studies, and physical examination were normal except for mild diffuse abdominal tenderness, hyperactive bowel sounds, and bulging flanks. An upper gastrointestinal series with small bowel follow through showed signs of partial small bowel obstruction. Abdominal CT revealed loculated abdominal and pelvic ascites with an associated peripheral rim enhancement (Figure A, arrow at peripheral rim enhancement). Paracentesis with analysis of peritoneal fluid revealed a transudative process. She subsequently underwent diagnostic laparotomy for persistent symptoms of suspected small bowel obstruction unresponsive to conservative measures. An unusual white encasing material around the peritoneum and small bowel wall without any strangulation or overt obstruction (Figure B, C) was noted. Peritoneal biopsy obtained at the time of the surgery contained acellular white clotted material with no findings of malignancy. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Patients with stage 3 compared to stage 4 liver fibrosis have lower frequency of and longer time to liver disease complications

Background and aims Advanced liver fibrosis is an important predictor of liver disease progression and mortality, and current guidelines recommend screening for complications of cirrhosis once patients develop F3 fibrosis. Our study compared liver disease progression and survival in patients with stage 3 (F3) and stage 4 (F4) fibrosis on liver biopsy. Methods Retrospective study of patients with F3 or F4 on liver biopsy followed for development of liver disease complications (variceal bleeding, ascites, and hepatic encephalopathy); hepatocellular carcinoma, and survival (overall and transplant free survival). Results Of 2488 patients receiving liver biopsy between 01/02 and 12/12, a total of 294 (171 F3) were analyzed. Over a median follow up period of 3 years, patients with F4 (mean age 53 years, 63% male) compared to F3 (mean age 49 years, 43% male) had higher five year cumulative probability of any decompensation (38% vs. 14%, p<0.0001), including variceal bleed (10% vs. 4%, p = 0.014), ascites (21% vs. 9%, p = 0.0014), and hepatic encephalopathy (14% vs. 5%, p = 0.003). F4 patients also had lower overall 5-year survival (80% vs. 93%, p = 0.003) and transplant free survival (80% vs. 93%, p = 0.002). Probability of hepatocellular carcinoma in 5 years after biopsy was similar between F3 and F4 (1.2% vs. 2%, p = 0.54). Conclusions Compared to F4 stage, patients with F3 fibrosis have decreased risk for development of liver disease complications and better survival. Prospective well designed studies are suggested with large sample size and overcoming the limitations identified in this study, to confirm and validate these findings, as basis for modifying guidelines and recommendations on follow up of patients with advanced fibrosis and stage 3 liver fibrosis.

Mo1167 Hypercoagulability and Autoimmune Risk Assessment is Important in Diabetic Gastroparesis

Introduction: There are reports of close contacts between nerve varicosities, smooth muscle cells, interstitial cells of Cajal (ICC) and fibroblast-like cells (PDGFR-α+ cells) in the gastrointestinal tract. Experimental studies of diabetes in animals suggest that the disease process can affect enteric nerves, extrinsic nerves, ICC and smooth muscle. By contrast, human data are sparse and generally inadequate for the validation of data obtained from experimental models. The aim of this study was to investigate histologic abnormalities in the gastric smooth muscle of patients with diabetes mellitus (DM). Methods: Full-thickness gastric specimens were obtained from patients undergoing surgery for gastric cancer. To investigate the pathological changes of stomach, H&E stain, Masson Trichrome stain and immunohistochemical examination were done on the sections. Antibodies against protein gene product (PGP) 9.5, neuronal NO synthase (nNOS), vasoactive intestinal peptide (VIP), neurokinin 1, c-Kit, and PDGFR-α were used. Immunofluorescent stain and evaluation with confocal microscopy were also done. Results: Tissues were collected from 26 controls, 21 short duration DM patients and 14 long duration DM patients (39 males/22 females, mean age 61.2 ± 9.6 y). In clinical characteristics, there were no significant differences of age and proportions of gender and upper gastrointestinal symptoms between DM group and control group. Mean BMI in the DM group was higher than that in the control group (p<0.05). The proportions of moderate to severe intercellular fibrosis in muscle layer were significantly higher in DM group than these in control group (p<0.01). On immunohistochemical staining, c-Kit and PDGFR-α positive immunoreactivity were significantly decreased in DM group compared with control group (p<0.05). There were no statistically significant differences in the PGP 9.5, nNOS, VIP and neurokinin 1 expression between DM group and control group. On immunofluorescent staining and confocal microscopic examinations, network of ICC and fibroblast-like cells in the muscle layer were greatly decreased in the DM group compared with control group. Conclusions: Our study suggests that on full-thickness gastric specimens, increased intercellular fibrosis and loss of ICC and fibroblast-like cells are found in the smooth muscle of patients with DM. These cellular abnormalities likely reduce the functional capacity of the gastrointestinal motor apparatus and may contribute to changes of gastrointestinal motility in patients with DM.