Umar Darr

Treat to Target in Inflammatory Bowel Disease: An Updated Review of Literature

Opinion statementTherapeutic management of patients with inflammatory bowel diseases (IBDs) has, for years, been tailored towards monitoring patient clinical presentation as a way to gauge therapeutic management. With the advent of newer biological agents, treatment and management have begun to focus on more objective rather than subjective parameters. These objective parameters include endoscopic targets and focus on the impact of mucosal healing, radiologic and histologic targets, patient reported outcomes, and use of non-invasive biomarkers. However, a recent consensus statement has identified clinical/patient-reported outcome (PRO) remission and endoscopic remission (defined as a Mayo endoscopic subscore of 0–1) as the target for UC with histological remission being an adjunctive goal. For CD, clinical/PRO remission defined as resolution of abdominal pain and diarrhea/altered bowel habit and endoscopic remission, defined as resolution of ulceration at ileocolonoscopy, and resolution of findings of inflammation on cross-sectional imaging in patients who cannot be adequately assessed with ileocolonoscopy were the primary targets. Biomarker remission (normal C-reactive protein (CRP) and calprotectin) was considered as an adjunctive target. This approach requires continuous monitoring and therapeutic adjustments with an aim to achieve the target. This article attempts to review the most updated literature regarding the treat to target approach and thus provides current recommendations and supported evidence.

Diagnosis of Pseudomyxoma peritonei via endoscopic ultrasound guided fine needle aspiration: a case report and review of literature

Abstract Introduction: Pseudomyxoma peritonei (PMP) is a rare condition caused by mucinous adenocarcinoma cancerous cells that produce abundance of mucin or gelatinous ascites. This cancer can cause tissue fibrosis and can impair normal organ function. Diagnosis can involve multiple imaging modalities including CT scan. There have been few cases of endoscopic ultrasound (EUS) being used as a means for diagnosis of this condition. Here we report a second case of PMP with a previous history of appendectomy diagnosed with EUS guided fine needle aspiration (FNA) biopsy. Case study: A 66-year-old male with a history of an appendectomy presented with intermittent abdominal pain for two years and weight loss of 40 pounds over two months. EGD and colonoscopy performed at an outside hospital was unremarkable. CT abdomen revealed perigastric ascities and lesions of the liver. ESR was elevated at 75. At our facility, EUS was performed revealing a peri-gastric and omental mass measuring 36.6 mm × 25.5 mm. FNA performed of both mass and ascetic fluid revealed low grade mucinous adenocarcinoma with mucinous deposits in the peritoneum consistent with PMP. Conclusions: Endoscopic ultrasound guided FNA, although very rarely used, can be a reliable and safe technique in diagnosis of PMP.

Diagnosis of Splenic Lymphoma by Endoscopic Ultrasound Guided Fine Needle Aspiration: A Case Report and Review of the Literature

Introduction. Splenic tumor is usually found as an incidental finding on CT of abdomen. Traditionally, ultrasound (US) or computed tomography (CT) guided biopsies were employed for the purpose of sampling; however they have been reported to have a complication rate of 5.3%. Endoscopic ultrasound-fine needle aspiration (EUS-FNA) has been recently utilized for the purpose of sampling splenic tumors. In literature there are 7 reported instances where splenic lymphoma was diagnosed using EUS-FNA. We present a case of follicular B cell lymphoma of the spleen diagnosed using EUS-FNA. Case Report. 58-year-old female presented to her primary care physician for left upper quadrant abdominal pain for one week. Physical exam was significant for left upper quadrant tenderness. Her laboratory tests were within normal limits. She underwent CT scan of abdomen which revealed approximately 5 cm × 5 cm mass in spleen. EUS-FNA of the spleen revealed a large hypoechoic, heterogeneous, well-demarcated mass measuring 54.7 mm × 43.0 mm. Fine needle aspiration was performed, and the sample was submitted for cytology and flow cytometry. Flow cytometry revealed a lambda monotypic population of B cells displaying dim CD19 and CD10. Diagnosis of B cell non-Hodgkin low grade follicular lymphoma was made. Conclusion. Endoscopic ultrasound with fine needle aspiration is a very rare but safe, reliable method of diagnosis of splenic lymphomas.

Transient Descending Colocolonic Intussusception Due to a Large Fecaloma in an Adult

Intussusception typically occurs in infants and children, with adults representing 5% of cases. A 53-year-old African American woman presented with lower abdominal pain and tenderness. Computed tomography of the abdomen and pelvis demonstrated a 3.5 cm colocolonic intussusception in the descending colon. Emergent colonoscopy found solid stool in the mid descending colon. Water-soluble rectal enema showed a filling defect in the mid descending colon. Repeat colonoscopy demonstrated presence of a large fecaloma in left colon. Laxatives were initiated, and abdominal pain subsided. To our knowledge, this is the first report of colocolonic intussusception secondary to fecaloma.

Renal Cell Carcinoma Presenting as an Ampullary Mass: A Case Report and Review of Literature

We present a case of a 60-year-old female patient who has significant medical history of renal cell carcinoma diagnosed 2 years back and had undergone right nephrectomy and chemotherapy. She presented to the hospital with complaints of abdominal pain and jaundice of 2 weeks duration and was found to have periampullary mass lesion causing compression of distal common bile duct on imaging with computed tomography of abdomen. Endoscopic retrograde cholangiography and endoscopic ultrasound showed ampullary mass lesion causing biliary obstruction along with abdominal lymphadenopathy. A temporary plastic stent was placed to relieve obstruction. Fine needle aspiration cytology of the periampullary mass along with immunohistochemical staining confirmed the diagnosis of metastatic renal cell carcinoma.

Viral Hepatitis in South Korea

In South Korea (S. Korea), viral hepatitis is a major public health burden. Advances in healthcare policy, evidence-based medicine, and therapeutic strategies in S. Korea have brought a rapid change in the sociodemographic and clinical characteristics of viral hepatitis. This review discusses the innovative approaches that S. Korea has taken to curb the epidemic of viral hepatitis. In addition, the efficacy of various preventive and therapeutic modalities is discussed. This review aims to provide a brief overview to guide future research direction and healthcare policy changes. How to cite this article: Pak SC, Alastal Y, Khan Z, Darr U. Viral Hepatitis in South Korea. Euroasian J Hepato-Gastroenterol 2017;7(2):163-165.

Long Esophageal Stricture in a Brittle Diabetic

Aim: We report a case of atypical esophageal stricture in a young diabetic woman. Background: Diabetes mellitus and gastroesophageal reflux disease (GERD) are two common disorders in modern society. Case report: A young diabetic woman developed a 6-cm-long esophageal stricture. This stricture was refractory to multiple esophageal dilation procedures. She underwent subtotal esophagectomy and had excellent treatment outcome. Conclusion: Gastroesophageal reflux disease can cause severe long esophageal stricture in a brittle diabetic. Clinical significance: Improving the awareness of their association between diabetes and GERD would greatly benefit the day-to-day practice of medicine. How to cite this article: Pak SC, Darr U, Alastal Y, Yoon Y. Long Esophageal Stricture in a Brittle Diabetic. Euroasian J Hepato-Gastroenterol 2017;7(2):191-192.

Concurrent Occurrence of Primary Biliary Cirrhosis and Rheumatoid Arthritis

Primary biliary cirrhosis (PBC) is an autoimmune cholestatic disorder of the liver. A diagnostic serum marker for PBC is an anti-mitochondrial antibody. Most prominent histologic findings of PBC are portal inflammation and destruction of interlobular bile ducts. The PBC occurs only in 40 to 400 individuals per million in the general population. About 1.8 - 5.6% of individuals with this rare disorder have rheumatoid arthritis (RA). This case report describes a 56-year-old female with concurrent rheumatoid arthritis and primary biliary cirrhosis. The patients with RA are at higher risk of developing PBC compared to the general population. Thus, abnormal liver function test in the patients with RA, especially in the absence of alternative cause, warrants thorough investigation for PBC. Early diagnosis and treatment will improve the outcome of patients who develop PBC.

Endoscopic Appearance of Oropharyngeal and Upper GI Kaposi’s Sarcoma in an Immunocompromised Patient

Introduction. Kaposis sarcoma (KS) usually manifests as a cutaneous disease but GI manifestation is often rare. It is associated with human herpes virus-8 (HHV-8) and seen in immunocompromised patients. In the USA, use of highly active antiretroviral therapy (HAART) has drastically reduced incidence of KS in HIV patients. Case Presentation. A 65-year-old male with human immunodeficiency virus (HIV) was admitted to the intensive care unit (ICU) with cardiopulmonary arrest secondary to hyperkalemia of 7.5 meq/L. Following placement of orogastric and endotracheal tube (ETT), a significant amount of blood was noticed in the ETT. Hemoglobin trended down from 9.6 mg/dL to 6.7 mg/dL over five days. Stool guaiac was positive. Esophagogastroduodenoscopy (EGD) was performed and revealed multiple large hypervascularized violaceous submucosal nodular lesions with stigmata of bleeding seen on the soft palate and pharynx and within the cricopharyngeal area close to the vocal cords. Biopsy of the soft palate lesions showed proliferation of neoplastic spindle shaped cells arranged in bundles with slit-like capillary spaces containing erythrocytes consistent with Kaposis sarcoma. Biopsy was positive for HHV-8. Colonoscopy was unremarkable. There were no cutaneous manifestations of the disease. Conclusion. GI involvement of Kaposis sarcoma must be considered in immunocompromised patients and can be confirmed by endoscopic methods.

Successful Endoscopic Treatment of Bouveret Syndrome in a Patient with Choledochoduodenal Fistula Complicating Duodenal Ulcer

Introduction Cholecystoduodenal fistulas represent the most common type of bilioenteric fistulas while choledochoduodenal fistulas account for only 1–25% of cases. Bilioenteric fistula cases are associated with cholelithiasis and are rarely associated with duodenal peptic ulcers. Here we present the first case of Bouveret syndrome secondary to choledochoduodenal fistula complicating peptic duodenal ulcer managed successfully via endoscopic mechanical lithotripsy. Case 86-year-old male with a medical history significant for coronary artery disease and stage 3 colorectal cancer status after resection and chemoradiation presented with intractable sharp abdominal pain worse postprandially for one week in duration, associated with early satiety, anorexia, and 5 lbs weight loss in one week. CT abdomen showed possible choledochoduodenal fistula and a distended stomach. An esophagogastroduodenoscopy (EGD) was performed revealing a large 2.5–3 cm stone lodged in the duodenal bulb at the base of duodenal ulcer with a fistula opening beneath it. The stone was extracted in 2 pieces via mechanical lithotripsy. Endoscopic ultrasound of the CBD revealed Riglers triad. Conclusion Bouveret syndrome is mostly associated with cholecystoduodenal fistula and has high mortality and morbidity due to underlying comorbid conditions and elderly age. Patients are not always fit for surgical management, and endoscopic management is not always successful.