Steven Carpenter

Endoscopic ultrasound is highly accurate and directs management in patients with neuroendocrine tumors of the pancreas

OBJECTIVE:Preoperative localization of pancreatic neuroendocrine tumors with traditional imaging fails in 40–60% of patients. Endoscopic ultrasound (EUS) is highly sensitive in the detection of these tumors. Previous reports included relatively few patients or required the collaboration of multiple centers. We report the results of EUS evaluation of 82 patients with pancreatic neuroendocrine tumors.METHODS:We prospectively used EUS early in the diagnostic evaluation of patients with biochemical or clinical evidence of neuroendocrine tumors. Patients had surgical confirmation of tumor localization or clinical follow-up of >1 yr.RESULTS:Eighty-two patients underwent 91 examinations (cases). Thirty patients had multiple endocrine neoplasia syndrome type I. One hundred pancreatic tumors were visualized by EUS in 54 different patients. The remaining 28 patients had no pancreatic tumor or an extrapancreatic tumor. Surgical/pathological confirmation was obtained in 75 patients. The mean tumor diameter was 1.51 cm and 71% of the tumors were ≤2.0 cm in diameter. Of the 54 explorations with surgical confirmation of a pancreatic tumor, EUS correctly localized the tumor in 50 patients (93%). Twenty-nine insulinomas, 18 gastrinomas, as well as one glucagonoma, one carcinoid tumor, and one somatostatinoma were localized. The most common site for tumor localization was the pancreatic head (46 patients). Most tumors were hypoechoic, homogenous, and had distinct margins. EUS of the pancreas was correctly negative in 20 of 21 patients (specificity, 95%). EUS was more accurate than angiography with or without stimulation testing (secretin for gastrinoma, calcium for insulinoma), transcutaneous ultrasound, and CT in those patients undergoing further imaging procedures. EUS was not reliable in localizing extrapancreatic tumors.CONCLUSIONS:In this series, the largest single center experience reported to date, EUS had an overall sensitivity and accuracy of 93% for pancreatic neuroendocrine tumors. Our results support the use of EUS as a primary diagnostic modality in the evaluation and management of patients with neuroendocrine tumors of the pancreas.

The clinical significance of focal active colitis

Focal crypt injury by neutrophils (cryptitis/crypt abscesses), or focal active colitis (FAC), is a common isolated finding in endoscopic colorectal biopsies. Focal active colitis is often thought of as a feature of Crohns disease, but may also be seen in ischemia, infections, partially treated ulcerative colitis, and as an isolated finding in patients undergoing endoscopy to exclude neoplasia. Clinical, endoscopic, and pathological data were retrospectively reviewed from 49 patients with focal active colitis, who had no other diagnostic findings on colorectal biopsy and no history of chronic inflammatory bowel disease. The histological findings were correlated with clinical diagnoses. Follow-up information was available for 42 of 49 focal active colitis patients. None developed inflammatory bowel disease; however, 19 patients had an acute self-limited colitis-like diarrheal illness, 11 had incidental focal active colitis (patients without diarrhea that were endoscoped to exclude colonic neoplasia and found to have asymptomatic FAC), 6 had irritable bowel syndrome, 4 had antibiotic-associated colitis, and 2 had ischemic colitis. Twenty patients were immunosuppressed, and 19 were taking nonsteroidal anti-inflammatory drugs. No histological features predicted final diagnoses. FAC did not predict the development of chronic colitis, even when mild crypt distortion or slight basal plasmacytosis was present. The preponderance of acute self-limited colitis and antibiotic-associated colitis among the FAC patients, along with the high number of immunosuppressed patients, support the conclusion that most FAC cases are infectious. The incidental detection of FAC in patients undergoing endoscopy to exclude colonic neoplasia was not clinically significant. The role of nonsteroidal anti-inflammatory drugs in FAC deserves further study.

Continuing Medical Education Questions: April 2018: ACG Clinical Guideline: Diagnosis and Management of Pancreatic Cysts

Continuing Medical Education Questions: April 2018: ACG Clinical Guideline: Diagnosis and Management of Pancreatic Cysts

Continuing Medical Education Questions: January 2017: Diagnosis and Management of Microscopic Colitis

Continuing Medical Education Questions: January 2017: Diagnosis and Management of Microscopic Colitis

Continuing Medical Education Questions: December 2017: Risk of Clostridium difficile Infection in Patients With Celiac Disease: A Population-Based Study

Continuing Medical Education Questions: December 2017: Risk of Clostridium difficile Infection in Patients With Celiac Disease: A Population-Based Study

Continuing Medical Education Questions: April 2017: Water Exchange Method Significantly Improves Adenoma Detection Rate: A Multicenter, Randomized Controlled Trial

Continuing Medical Education Questions: April 2017: Water Exchange Method Significantly Improves Adenoma Detection Rate: A Multicenter, Randomized Controlled Trial

Continuing Medical Education Questions: June 2016

2. A 35-year-old man with a known history of celiac disease is evaluated for a 3-month history of diarrhea (2-4 loose stools per day) and intermittent abdominal pain with bloating. Previously, he noted resolution of weight loss, diarrhea, and abdominal pain in response to a strict gluten-free diet. He has no evidence for gastrointestinal bleeding and he takes no medications. His physical exam and laboratory values are normal. Now, despite strict adherence to a gluten-free diet, his symptoms are poorly controlled, and he asks about other therapies for the management of his celiac disease.

Continuing Medical Education Questions: August 2016

1. A 76-year-old white female presents with regurgitation, heartburn, and dyspepsia. She has no history of dysphagia, weight loss, or early satiety. Th ere is no family history of gastrointestinal malignancy. On physical exam, she appears healthy with a BMI of 26 kg/m 2 , and her vital signs are normal. Upper endoscopy is notable for chronic-appearing gastritis. No mass, ulceration, pyloric stricture, mucosal nodularity, or gastric fold thickening was identifi ed. Antral biopsies demonstrate gastric intestinal metaplasia without evidence for dysplasia.

Continuing Medical Education Questions: March 2016

1. A 66-year-old female presents with a history of chronic constipation and rectal bleeding. She did not pursue colon cancer screening previously. She has a history of hypertension, current tobacco use, diabetes mellitus type II, and medically complicated obesity. An obstructing fi rm mass is identifi ed in the distal sigmoid colon during colonoscopy. Biopsies demonstrate moderately diff erentiated adenocarcinoma. Due to the obstructing lesion, complete colonoscopy was not possible. CT scan with IV and oral contrast revealed thickening of the sigmoid colon. Th e liver and the unexamined aspects of the colon were normal. Preoperative labs were notable for normal liver tests and a CEA of 0.8. Her surgical resection was successful. Pathology confi rms moderately diff erentiated adenocarcinoma and none of the 32 nodes examined were notable for metastasis.

Continuing Medical Education Questions: December 2015

QUESTIONS: 1. A 66-year-old female presents for her fi rst screening colonoscopy. She has a history of chronic constipation, current tobacco use, diabetes mellitus type II, and medically complicated obesity (BMI 35.4 kg/m2). Her pre-procedure vital signs were stable, and propofol sedation was used. During the procedure, cecal intubation was documented by photographs of the appendiceal orifi ce, terminal ileum, and ileocecal valve. Bowel preparation was fair. During the withdrawal phase of the exam, she develops a loud sonorous breathing pattern and her O2 saturation drops below 90%, possibly due to sleep apnea. One 6-mm sessile suspected adenoma is resected quickly by cold snare in the descending colon. Upon completion of her colonoscopy, her O2 saturation is greater than 92%. Your withdrawal time for the procedure was 4 minutes and 15 seconds.