Terrence J. Frick

Gastrointestinal bleeding from a brunner's gland hamartoma: characterization by endoscopy, computed tomography, and endoscopic ultrasound

Brunner’s gland hamartoma (also referred to as adenoma or Brunneroma) is a rare tumor of the duodenum that was first described by Salvioli in 1876 (1). Although commonly an incidental finding, Brunner’s gland hamartomas can lead to clinically significant symptoms including GI bleeding, abdominal pain, and intestinal obstruction (1–11). The natural history of these lesions has not been well defined. We describe the endoscopic, the endoscopic ultrasound (EUS), and the computed tomography (CT) characteristics of a large Brunner’s gland hamartoma that was present for two decades and resulted in upper GI bleeding.

Predictors of Malignancy and Recommended Follow-Up for Patients with Negative Endoscopic Ultrasound-Guided Fine-Needle Aspiration of Suspected Pancreatic Lesions

BACKGROUND Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) can characterize and diagnose pancreatic lesions as malignant, but cannot definitively rule out the presence of malignancy. Outcome data regarding the length of follow-up in patients with negative or nondiagnostic EUS-FNA of pancreatic lesions are not well-established. OBJECTIVE To determine the long-term outcome and provide follow-up guidance for patients with negative EUS-FNA diagnosis of suspected pancreatic lesions based on imaging predictors. METHODS A retrospective review of patients undergoing EUS-FNA for suspected pancreatic lesions, but with negative or nondiagnostic FNA results was conducted at a tertiary care referral medical centre. Patient demographics, EUS imaging characteristics and follow-up data were examined. RESULTS Seventeen of 55 patients (30.9%) with negative/nondiagnostic FNA were subsequently diagnosed with pancreatic malignancy. The risk of cancer was significantly higher for patients who had associated lymph nodes on EUS (P<0.001) and vascular involvement on EUS (P=0.001). The mean time to diagnosis in the group with falsenegative EUS-FNA diagnosis was 66 days. The true-negative EUSFNA patients were followed for a mean of 403 days after negative EUS-FNA results without the development of malignancy. CONCLUSION For patients undergoing EUS-FNA for a suspected pancreatic lesion, a negative or nondiagnostic FNA does not provide conclusive evidence for the absence of cancer. Patients for whom vascular invasion and lymphadenopathy are detected on EUS are more likely to have a true malignant lesion and should be followed closely. When a patient has been monitored for six months or more with no cancer being diagnosed, there appears to be much less chance that a pancreatic malignancy is present.

Differentiating primary pancreatic lymphoma from adenocarcinoma using endoscopic ultrasound characteristics and flow cytometry: A case-control study

Background: Primary pancreatic lymphoma (PPL) is a rare pancreatic neoplasm that is difficult to diagnose. PPL has a vastly different prognosis and treatment regimen than other pancreatic tumors; therefore, accurate diagnosis is vital. In this article, we describe the characteristic presentation, endoscopic ultrasound (EUS) features, and the role of fine-needle aspiration (FNA) in the diagnosis of PPL compared with pancreatic adenocarcinoma. Materials and Methods: This was a retrospective case-control study of 11 patients diagnosed with PPL via EUS between 2002 and 2011. The clinical and EUS features of the cases were then compared with age-matched controls with adenocarcinoma in a 1:3 ratio. Results: There were 11 patients with PPL and 33 with adenocarcinoma. At last follow-up, 7 of 11 PPL patients were alive, and 3 of 33-adenocarcinoma patients were alive (P < 0.001). The most common presenting symptoms for PPL were pain 73%, weight loss 45%, and jaundice 18%, while patients with adenocarcinoma presented with pain 52% (P = 0.3), weight loss 30% (P = 0.47) and jaundice 76% (P = 0.001). The EUS appearance was similar in the two groups in that ultrasound imaging of the pancreas lesions tended to be hypoechoic and heterogenous, but the PPL group was more likely to have peripancreatic lymphadenopathy (LAD) (64% vs. 18%, P = 0.008) and were larger (4.8 cm × 5.3 cm vs. 3.2 cm × 3.1 cm, P < 0.001). The PPL group was less likely to have vascular invasion (18% vs. 55%, P = 0.045) and less likely to be found in the head of the pancreas (36% vs. 85%, P = 0.004). FNA and cytology (without flow cytometry [FC]) made the diagnosis in 28% of PPL patients compared with 91% of adenocarcinoma patients (P = 0.002). In the PPL group, 7 of 11 FNA samples were sent for FC. If FC was added, then the diagnosis of PPL was increased to 100%. Conclusions: Compared with adenocarcinoma, pancreatic lymphoma has a better prognosis, is less likely to present with jaundice and less likely to have vascular invasion. PPL is more likely to be located outside the head of the pancreas and to include peripancreatic LAD, and is less likely to be diagnosed with cytology. The diagnostic accuracy of FNA for PPL is improved greatly with the addition of FC.

Dilation of Malignant Strictures in Endoscopic Ultrasound Staging of Esophageal Cancer and Metastatic Spread of Disease

Background. Dilation of malignant strictures in endoscopic ultrasound (EUS) staging of esophageal cancer is safe, but no data exists regarding the subsequent development of metastases. Aim. Compare the rates of metastases in esophageal cancer patients undergoing EUS staging who require esophageal dilation in order to pass the echoendoscope versus those who do not. Methods. We reviewed consecutive patients referred for EUS staging of esophageal cancer. We evaluated whether dilation was necessary in order to pass the echoendoscope, and for the subsequent development of metastases after EUS at various time intervals. Results. Among all patients with similar stage (locally advanced disease, defined as T3, N0, M0 or T1-3, N1, M0), there was no difference between the dilated and nondilated groups in the rates of metastases at 3 months (14% versus 10%), P = 1.0, 6 months (28% versus 20%), P = 0.69, 12 months (43% versus 40%), P = 1.0, or ever during a mean followup of 15 months (71% versus 55%), P = 0.48. Conclusions. Dilation of malignant strictures for EUS staging of esophageal cancer does not appear to lead to higher rates of distant metastases.

P-132 YI Experience with Low-Dose Mycophenolate for the Inflammatory Bowel Disease Population

BACKGROUND: Thiopurines (azathioprine/6-mercaptopurine) are the first-line immunomodulators for inflammatory bowel disease (IBD). Mycophenolate has been used as an alternative in patients intolerant to conventional thiopurine therapy but there is a paucity of data supporting the use of this medication for IBD. METHODS: Patients treated with mycophenolate for IBD were identified from over a 14 year period (1998–2012) from a single academic center using an electronic medical record. Charts were reviewed for demographic data, history of medical treatment for IBD including mycophenolate exposure, and adverse reactions to these medications. Patients treated with mycophenolate for conditions other than IBD such as immunosuppression for post-solid organ transplantation were excluded. RESULTS: Sixty-four patients were identified with IBD (19 ulcerative colitis, 44 Crohn’s disease, 1 indeterminate colitis) that has been treated with mycophenolate during the study period. Ninety-five percent (n = 61/64) were treated with thiopurines prior to mycophenolate. Four patients died during the study period, 7 patients were lost to follow-up, and 27 patients discontinued mycophenolate. Mycophenolate therapy averaged 45.5 months (3.8 years) per patient for a total 242.7 patient-years. The mean maximum daily dosage was 1,540 mg. Sixty-nine percent (n = 44/64) were started on mycophenolate because of thiopurine intolerance (e.g., pancreatitis, leucopenia, side effects) and 23% (n = 15/64) were started on mycophenolate because of thiopurine ineffectiveness. Forty-one percent (n = 26/64) remained on mycophenolate therapy at the study conclusion, with a mean length of treatment of 5.3 years for these patients. Twenty-seven patients discontinued mycophenolate with 6 patients stopping due to advancing to surgery, 5 due to ineffectiveness, 4 due to gastrointestinal symptoms (i.e., nausea, vomiting, diarrhea). Two patients stopped because of medication cost. CONCLUSIONS: Most patients treated with mycophenolate at our institution received the drug after failing or demonstrating intolerance to a thiopurine. Low-dose mycophenolate appeared safe and well tolerated in this group and was not associated with serious adverse outcomes. Further randomized controlled clinical trials with mycophenolate for IBD should be considered, given the clinical need for alternative immunomodulators for patients with thiopurine intolerance.

Ileoanal Pouch Inlet Obstruction Following Cesarean Section

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