Walid Chalhoub

Drug-induced liver injury: what was new in 2013?

Introduction: The year 2013 continued to highlight numerous aspects of drug-induced liver injury (DILI), with new information communicated via > 1500 publications. New reports of DILI were described and FDA warnings and alerts were issued for a number of products, emphasizing the risks related to hepatotoxicity. Areas covered: We provide a summary of the years published reports of new causes of DILI, along with reviews and reports of established hepatotoxins, new and expanded DILI registries and the continuing emphasis placed on genetic and other risk factors. Several new analyses of data generated from the US DILI Network are included. Expert opinion: The clinical usefulness of pharmacogenetic testing remains to be determined; the number of patients who must be tested is large and the overall risk of DILI is quite small. The role that dose and hepatic metabolism play in causing idiosyncratic DILI was reviewed; daily doses > 50 – 100 mg of medications with high lipophilicity appear to be most predictive of severe DILI, but not in all cases. Restricting access to paracetamol in certain parts of the UK continues to demonstrate a successful reduction in the number of acute liver failure cases and patients listed for liver transplant.

Gastric antral webs in adults: A case series characterizing their clinical presentation and management in the modern endoscopic era

AIM To investigate the current management of gastric antral webs (GAWs) among adults and identify optimal endoscopic and/or surgical management for these patients. METHODS We reviewed our endoscopy database seeking to identify patients in whom a GAW was visualized among 24640 esophagogastroduodenoscopies (EGD) over a seven-year period (2006-2013) at a single tertiary care center. The diagnosis of GAW was suspected during EGD if aperture size of the antrum did not vary with peristalsis or if a “double bulb” sign was present on upper gastrointestinal series. Confirmation of the diagnosis was made by demonstrating a normal pylorus distal to the GAW. RESULTS We identified 34 patients who met our inclusion criteria (incidence 0.14%). Of these, five patients presented with gastric outlet obstruction (GOO), four of whom underwent repeated sequential balloon dilations and/or needle-knife incisions with steroid injection for alleviation of GOO. The other 29 patients were incidentally found to have a non-obstructing GAW. Age at diagnosis ranged from 30-87 years. Non-obstructing GAWs are mostly incidental findings. The most frequently observed symptom prompting endoscopic work-up was refractory gastroesophageal reflux (n = 24, 70.6%) followed by abdominal pain (n = 11, 33.4%), nausea and vomiting (n = 9, 26.5%), dysphagia (n = 6, 17.6%), unexplained weight loss, (n = 4, 11.8%), early satiety (n = 4, 11.8%), and melena of unclear etiology (n = 3, 8.82%). Four of five GOO patients were treated with balloon dilation (n = 4), four-quadrant needle-knife incision (n = 3), and triamcinolone injection (n = 2). Three of these patients required repeat intervention. One patient had a significant complication of perforation after needle-knife incision. CONCLUSION Endoscopic intervention for GAW using balloon dilation or needle-knife incision is generally safe and effective in relieving symptoms, however repeat treatment may be needed and a risk of perforation exists with thermal therapies.

Lymphangioma Presents as Peripancreatic Cystic Neoplasm: The Utility of Endoscopic Ultrasound

Pancreatic lymphangiomas are very rare benign cystic lesions that arise from abnormal proliferation of the lymphatic vessels. Although benign, pancreatic lymphangiomas may mimic more concerning cystic neoplasms and therefore require a thorough diagnostic workup. Herein we report a case of a 50-year-old female who presented with a peripancreatic cyst measuring 2.5x3.6x4.7cm that was discovered incidentally during an abdominal ultrasound. She underwent endoscopic ultrasound with fine needle aspiration where chylous fluid was drained. Cytology was negative for malignancy and fluid chemistry demonstrated a significantly elevated triglyceride level consistent with a pancreatic lymphangioma. It is unclear whether asymptomatic pancreatic lymphangiomas are best managed conservatively or with surgical intervention. The patient has not proceeded with surgery at this time.

Retroperitoneal Schwannoma Presents as a Peripancreatic Cystic Structure: The Utility of EUS/FNA in the Diagnosis

Retroperitoneal schwannomas are extremely rare tumors that arise from the Schwann cell of the peripheral nerves. Patients are typically asymptomatic, however, large tumors may lead to the development of abdominal pain or obstructive symptoms. Herein we describe a case of a 57 year-old male with a known peripancreatic cystic mass presenting with new onset abdominal pain and a CT demonstrating a 40 × 42 mm peripancreatic cystic structure previously 17 × 20 mm. Endoscopic ultrasound with fine needle aspiration was performed and cytological examination revealed a peripheral nerve sheath tumor. The patient underwent uneventful laparoscopic resection. Analysis of the surgical specimen revealed a spindle cell tumor with positive S100, negative CD117/CD34 and pancytokeratin consistent with a schwannoma

Gastric Duplication Cyst With Elevated Amylase: An Unusual Presentation Mimicking Pancreatic Cystic Neoplasm.

Enteric duplication cysts (EDCs) are benign congenital anomalies that are found incidentally in adults. Gastric duplication cysts (GDCs) are the least common subtype of EDC, but when located near the pancreas, may resemble other neoplastic conditions. We report a case of GDC adjacent to the pancreas with high cystic fluid amylase and carcinoembryonic antigen (CEA) and 3 different epithelia (respiratory, gastric, and intestinal), all diagnosed via endoscopic ultrasound with fine-needle aspiration.

Endosonographic Findings in Colitis Cystica Profunda

A 27-year-old male was referred to our institution for further evaluation of persistent rectal bleeding. A prior colonoscopy showed a sigmoid soft tissue lesion, and pathology revealed chronic active colitis and granulation tissue with ulcers and focal adenomatous changes. We performed a flexible sigmoidoscopy that showed a 4.5-cm multilobulated polypoid lesion approximately 45 cm from the anal verge (Figure 1). A 20 MHz Olympus endoscopic ultrasound (EUS) miniprobe showed hypoechoic lesion with cystic/spongy features involving the mucosa and submucosa (Figure 2). These features were thought to suggest colitis cystica profunda (CCP). Histologic examination of snare biopsies identified dilated glands with mucinous content, surrounded by variable degrees of fibrosis on a background of interspersed chronic inflammatory cells, with few colonic mucosal crypts and mild inflammatory cell infiltrate (Figure 3). The patient was instructed to follow up with gastroenterology if bleeding recurred.