William J. Salyers

Neuroendocrine tumors of the gastrointestinal tract: Case reports and literature review

Neuroendocrine tumors (NET) previously called carcinoid tumors are neoplasms of enterochromaffin/neuroendocrine cell origin which display neurosecretory capacity that may result in the carcinoid syndrome. The annual incidence of patients with NET is 8.4 per 100000; yet many NET remain asymptomatic and clinically undetected. A majority of NET follows a benign course; however, some will display malignant characteristics. NET most commonly occur in the gastrointestinal tract (67%) and bronchopulmonary system (25%). Gastrointestinal NET occur within the stomach, small intestine, liver, and rectum. We report a retrospective study of 11 subjects: Eight with benign carcinoid tumors: duodenal bulb (n = 2), terminal ileum (n = 1), sigmoid colon (n = 2), and rectum (n = 3); three with malignant carcinoid: liver (n = 1) and intra-abdominal site (n = 2). The diagnosis, endoscopic images, outcome, treatment and review of the literature are presented.

Delayed Splenic Rupture: Myth or Reality?

Introduction The spleen is the most commonly injured organ in blunt abdominal trauma.1 Most splenic injuries manifest immediately after trauma, however, delayed splenic rupture (DSR) may occur days to weeks following a blunt abdominal trauma. It has been debated whether delayed splenic rupture is simply a delayed diagnosis of a missed contained splenic rupture or rather an initially latent splenic lesion that may have been undetected by conventional imagery and evolved later to rupture. 2,3

Colon cancer metastasis to mediastinal lymph nodes without liver or lung involvement: A case report

Colon cancer is the second most common type of cancer in females and the third in males, worldwide. The most common sites of colon cancer metastasis are the regional lymph nodes, liver, lung, bone and brain. In this study, an extremely rare case of colon adenocarcinoma with extensive metastasis to the mediastinal lymph nodes without any other organ involvement is presented. A 44-year-old Caucasian male presented with abdominal pain, a change in bowel habits, melena and weight loss. Colonoscopy revealed a large friable, ulcerated, circumferential mass in the ascending colon. Biopsies were consistent with the diagnosis of invasive moderately differentiated adenocarcinoma. Subsequently, right colon resection was performed, and pathological analysis revealed moderately differentiated adenocarcinoma of the right colon with extensive regional lymph node involvement. Computed tomography (CT) scans of the chest, abdomen and pelvis were performed preoperatively as part of routine staging for colon cancer. No liver or lung pathology was identified; however, multiple pathologically enlarged mediastinal lymph nodes were observed. Endoscopic ultrasound with fine needle aspiration of the largest mediastinal lymph node, which measured 5.2×3.5 cm on CT scans, was performed. The pathology was again consistent with the diagnosis of metastatic colorectal primary adenocarcinoma. At present, no optimum treatment has been identified for metastatic colon cancer to the mediastinal lymph nodes. The patient in the current case received chemotherapy with folinic acid, fluorouracil and oxaliplatin (FOLFOX), as well as with bevacizumab. Initial follow-up CT scans of the chest revealed a positive response to treatment. Physicians, in particular, radiologists, must consider the mediastinum during the first evaluation and further follow-up of patients with colorectal carcinoma even in the absence of metastasis.

Recurrence of a Pancreatic Cystic Lymphangioma After Diagnosis and Complete Drainage by Endoscopic Ultrasound with Fine-Needle Aspiration

CONTEXT Lymphangiomas are uncommon benign neoplasms that result from a blockage of the lymphatic system. Pancreatic cystic lymphangiomas are extremely rare. Pancreatic cystic lymphangiomas have been classically diagnosed on histopathologic examination following surgical excision, but recent reports have demonstrated successful diagnosis using endoscopic ultrasound with fine-needle aspiration (EUS-FNA). Data on the natural history of these lesions following drainage via EUS-FNA are lacking. We present a case of successful initial diagnosis and drainage of a pancreatic cystic lymphangioma using EUS-FNA, with unfortunate recurrence of the lesion four months later. CASE REPORT A 50-year-old female was evaluated for epigastric abdominal pain and nausea. CT scan revealed a 4 cm retroperitoneal cystic lesion. EUS-FNA was performed with complete drainage of the lesion using a 22-gauge needle. Twenty-five mL of chylous white fluid was obtained with laboratory analysis consistent with a pancreatic cystic lymphangioma. The patient was symptom-free for 4 months following drainage, but eventually had symptoms again with a CT scan confirming recurrence. CONCLUSIONS While EUS-FNA is effective for the diagnosis of pancreatic cystic lymphangiomas, its role in the management of these lesions is questionable. Temporary relief of symptoms can be achieved after EUS-guided drainage, but recurrence is a concern. Definitive cure likely requires complete surgical excision.

Gastrointestinal Amyloidosis: Review of the Literature

Gastrointestinal amyloidosis (GIA), a protein deposition disorder, represents a complex common pathway that encompasses multiple etiologies and presentations. It represents a significant diagnostic and treatment challenge. The disease results from the deposition of insoluble extracellular protein fragments that have been rendered resistant to digestion. GIA can be acquired or genetic, and most commonly results from chronic inflammatory disorders (AA amyloidosis), hematologic malignancy (AL amyloidosis), and end-stage renal disease (Beta-2 amyloidosis). The deposition of these abnormal proteins interferes with gastrointestinal tract (GI) organ structure and function, most notably in the liver and small bowel. Presentation from GI involvement includes cirrhotic sequelae, abdominal pain, malabsorption, and GI bleeding. Diagnosis hinges on pathologic examination of affected tissue, with classic green birefringence under polarized light. Abdominal fat pad and rectal mucosal biopsy have been described as sites of higher sensitivity for diagnosis. Serum amyloid P scintigraphy is near 90% sensitive for diagnosis of AA amyloidosis. Patients should be considered for further evaluation to rule out additional organ involvement, notably cardiac and renal. Treatment hinges on an adequate suppression of the predisposing inflammatory disorder, or malignancy, followed by supportive therapy. Prognosis varies depending on the etiology of the disease, with the AL subtype showing worse outcomes, as well as those with hepatic involvement.

Under-diagnosing and under-treating iron deficiency in hospitalized patients with gastrointestinal bleeding.

AIM To determine whether patients hospitalized with gastrointestinal (GI) blood loss anemia are being checked and treated for iron deficiency. METHODS Retrospective chart review was conducted for all patients admitted to a single tertiary care hospital between 11/1/2011 and 1/31/2012 for any type of GI bleeding. The primary endpoint was the percentage of patients who had their iron studies checked during a hospitalization for GI blood loss anemia. Secondary outcomes included percentage of anemic GI bleeders who had adequate documentation of anemia and iron deficiency, and those who were treated for their iron deficiency. Then we tried to identify possible predictors of checking iron studies in an attempt to understand the thought process that physicians go through when managing these patients. Iron deficiency was defined as Iron saturation less than 15% or ferritin level less than 45 μg/L. Anemia was defined as hemoglobin level less than 13 g/dL for males and 12 g/dL for females. RESULTS Three hundred and seven GI bleeders were hospitalized during the study period, and 282 of those (91.9%) had anemia during their hospital stay. Ninety-five patients (30.9%) had iron studies performed during hospitalization, and 45 of those (47.4%) were actually found to be iron deficient. Only 29 of those 45 iron deficient patients were discharged home on iron supplements. Of the 282 patients that had anemia during hospitalization, 50 (17.7%) had no documentation of the anemia in their hospital chart. Of the 45 patients that had lab proven iron deficiency anemia (IDA), only 22 (48.5%) had documentation of IDA in at least one note in their chart. Predictors of checking iron studies in anemic GI bleeders were lower mean corpuscular volume, documentation of anemia, having fecal occult blood testing, not having hematemesis or past history of GI bleeding. There were no significant differences between the teaching and non-teaching services in any patient characteristics or outcomes. CONCLUSION Iron deficiency is under-diagnosed, under-recognized even when iron studies were checked, and under-treated in hospitalized patients with GI bleeding.

Primary Hepatic Angiosarcoma Mimicking Multifocal Liver Abscess with Disseminated Intravascular Coagulation and Hemoperitoneum

Primary hepatic angiosarcoma (PHA), a rare and aggressive malignancy, has rarely been reported to present with disseminated intravascular coagulation with liver hemorrhage. Incidence is estimated at 0.5–2.5 cases per 10,000,000. To our knowledge, it has not been reported to mimic liver abscess with a septic presentation. Advanced imaging techniques may aid in the diagnosis, though biopsy with microscopy and immunohistochemistry is the mainstay. Prognosis is very poor, with a 5-year survival rate estimated at 6.4%. We present the case of a 70-year-old man who presented with sepsis thought to be due to a multifocal liver abscess, who did not respond to drainage and antibiotics. This atypical course led to further workup which subsequently revealed a diagnosis of PHA.

Primary Squamous Cell Carcinoma of the Pancreas as a Cause of Biliary Obstruction

Primary squamous cell carcinoma of the pancreas (SCCP) is a rare neoplasm, given a lack of naturally occurring squamous cells within the pancreas, accounting for only 0.2% of all pancreatic cancers. The etiology is unknown. Symptomatology is non-specific and similar to other pancreatic neoplasms. No non-invasive testing can adequately rule in SCCP, and workup should proceed similarly to any pancreatic mass. Tissue sampling is required for diagnosis and guidance of further management, most commonly by endoscopic ultrasound with fine needle aspirate. SCCP is more aggressive than adenocarcinoma of the pancreas with a median survival of three and ten months for those treated with palliative and surgical intent, respectively. The optimal treatment regimen remains unknown, though the uses of radiation therapy, platinum-based regimens, gemcitabine, and 5-FU have all been reported with favorable results. We present a case of primary SCCP in an 81-year-old female who presented with jaundice.

Mo1963 Under-Diagnosing and Under-Treating Iron-Deficiency in Hospitalized Patients With Acute Gastrointestinal Bleeding: Retrospective Cohort Preliminary Results

Background and aim: Gastrointestinal (GI) bleeding is the major cause of iron deficiency in men and post-menopausal women. The aim of this study is to determine whether patients admitted to the hospital with acute gastrointestinal blood loss anemia are being worked up for concomitant highly prevalent iron deficiency and adequately treated for it. Methods: Retrospective chart review of all patients admitted to a single tertiary care hospital between 11/1/2011 and 11/1/2012 for any type of gastrointestinal bleeding. The primary endpoint was the percentage of patients with iron studies performed during a hospitalization for GI blood loss anemia. Secondary outcomes included prevalence of iron deficiency in acute GI bleeders, percentage of anemic patients hospitalized for GI bleeding who had adequate documentation of anemia and iron deficiency, and those who were treated for their iron deficiency. Secondary outcomes also included identifying possible predictors of checking iron studies. Results: 126 charts of patients hospitalized for GI bleeding have been reviewed so far. 100 patients (79.4%) had anemia on admission, while 119 (94.4%) had anemia at some point during their hospitalization. 62 were transfused at least 1 unit of packed red blood cells. Out of 126 patients, only 34 (27%) had iron studies performed during hospitalization. 19 out of 34 had iron deficiency (55.9%) defined as serum Ferritin <45 ng/mL or transferrin iron saturation <15%. None of the 126 patients were discharged with recommendations to their primary care physicians to check iron studies as an outpatient. Out of 126 patients included so far in this cohort, 16 (12.7%), 27 (21.4%), and 23 (18.3%) were on iron supplements prior to their current hospitalization, received iron therapy during hospitalization, and were discharged on iron supplements, respectively. Out of the 19 patients with proven iron deficiency, only 12 (63.2%) received iron therapy during hospitalization while only 9 (47.4%) got discharged on iron supplements. 41 patients (32.5%) were admitted to a residency teaching service and 85 (67.5%) to a hospitalist non-teaching service. There were no significant differences between the 2 services in any patient characteristics or outcomes. Out of 119 patients that had anemia during hospitalization, 17 (14.3%) had no documented anemia in their chart, 10 (8.4%) had a documented iron deficiency anemia, and 92 (77.3%) had a documented anemia diagnosis in their chart without specification whether iron deficient or not. On multivariable analysis, the only predictors of checking iron studies were a lower hemoglobin (p=0.01; OR=1.6 (1.1-2.2)) and occult bleeding (p= 0.001; OR=7.1 (2.3-25.0)) Conclusion: Iron deficiency is under-diagnosed, under-recognized even when iron studies were checked, and finally under-treated in hospitalized patients with gastrointestinal bleeding.