Wilson Kwong

Low Rates of Malignancy and Mortality in Asymptomatic Patients With Suspected Neoplastic Pancreatic Cysts Beyond 5 Years of Surveillance

BACKGROUND & AIMS The 2015 American Gastroenterological Association guidelines recommend discontinuation of surveillance of pancreatic cysts after 5 years, although there are limited data to support this recommendation. We aimed to determine the rate of pancreatic cancer development from neoplastic pancreatic cysts after 5 years of surveillance. METHODS We performed a retrospective multicenter study, collecting data from 310 patients with asymptomatic suspected neoplastic pancreatic cysts, identified by endoscopic ultrasound from January 2002 to June 2010 at 4 medical centers in California. All patients were followed up for 5 years or more (median, 87 mo; range, 60-189 mo). Data were used to calculate the risk for pancreatic cancer and all-cause mortality. RESULTS Three patients (1%) developed invasive pancreatic adenocarcinoma. Based on American Gastroenterological Association high-risk features (cyst size > 3 cm, dilated pancreatic duct, mural nodule), risks for cancer were 0%, 1%, and 15% for patients with 0, 1, or 2 high-risk features, respectively. Mortality from nonpancreatic causes was 8-fold higher than mortality from pancreatic cancer after more than 5 years of surveillance. CONCLUSIONS There is a very low risk of malignant transformation of asymptomatic neoplastic pancreatic cysts after 5 years. Patients with pancreatic lesions and 0 or 1 high-risk feature have a less than 1% risk of developing pancreatic cancer, therefore discontinuation of surveillance can be considered for select patients. Patients with neoplastic pancreatic cysts with 2 high-risk features have a 15% risk of subsequent pancreatic cancer, therefore surgery or continued surveillance should be considered.

Low yield of routine duodenal biopsies for evaluation of abdominal pain

AIM To determine the yield of biopsying normal duodenal mucosa for investigation of abdominal pain. METHODS This is a retrospective chart review of consecutive patients who underwent esophagogastroduodenoscopy (EGD) with duodenal biopsies of normal appearing duodenal mucosa for an indication that included abdominal pain. All the patients in this study were identified from an electronic endoscopy database at a single academic medical center and had an EGD with duodenal biopsies performed over a 4-year period. New diagnoses that were made as a direct result of duodenal biopsies were identified. All duodenal pathology reports and endoscopy records were reviewed for indications to perform the examination as well as the findings; all the medical records were reviewed. Exclusion criteria included age less than 18 years, duodenal mass, nodule, or polyp, endoscopic duodenitis, duodenal scalloping, known celiac disease, positive celiac serology, Crohns disease, or history of bone marrow transplant. Information was collected in a de-identified database with pertinent demographic information including human immunodeficiency virus (HIV) status, and descriptive statistics were performed. RESULTS About 300 patients underwent EGD with biopsies of benign appearing or normal appearing duodenal mucosa. The mean age of patients was 44.1 ± 16.8 years; 189 of 300 (63%) were female. A mean of 4.3 duodenal biopsies were performed in each patient. In the subgroup of patients with abdominal pain without anemia, diarrhea, or weight loss the mean age was 43.4 ± 16.3 years. Duodenal biopsies performed for an indication that included abdominal pain resulting in 4 new diagnoses (3 celiac disease and 1 giardiasis) for an overall yield of 1.3%. 183 patients with abdominal pain without anemia, diarrhea, or weight loss (out of the total 300 patients) underwent duodenal biopsy of duodenal mucosa resulting in three new diagnoses (two cases of celiac disease and one giardiasis) for a yield of 1.6%. Duodenal biopsies of 19 HIV patients presenting for evaluation of abdominal pain did not reveal any new diagnoses. Information pertaining to new diagnoses is provided. CONCLUSION Routine biopsy of normal appearing duodena in patients with abdominal pain should be reserved for those with a high pre-test probability given its low diagnostic yield.

Percutaneous endoscopy to diagnose malignancy in gastric outlet obstruction of excluded stomach after gastric bypass

Gastric cancer in the excluded stomach after Roux-en-Y gastric bypass is a rare finding and most reported diagnoses are made via surgery. Endoscopic access to the excluded stomach is difficult, even with balloon-assisted enteroscopy. We present the case of a 74-year-old woman with malignant gastric outlet obstruction of the excluded stomach, 41 years after Roux-en-Y gastric bypass. Minimally invasive access to the excluded stomach was obtained by placement of a percutaneous gastrostomy tube, followed by insertion of a pediatric gastroscope through the gastrostomy tube tract. This novel approach provides minimally invasive access to the excluded stomach in patients with high suspicion of pathology in the excluded stomach, when balloon-assisted enteroscopy is not technically feasible or available.

A modern form of Rapunzel syndrome: trichobezoar composed of synthetic hair extensions.

20-year-old woman presented to the emergency Aroomwith severemidepigastric pain and vomiting. Her symptoms progressed over several weeks and she eventually was unable to eat solid foods without vomiting, although she could tolerate liquids. She lost 15 lb in this setting. Her physical examination was significant for a firm, tender mass in the midepigastrum. Laboratory test results showed a leukocytosis of 16,200/mm, with normal liver chemistries and lipase. An abdominal film showed a large opacity within the stomach displacing the transverse colon inferiorly. An abdominal computed tomography scan confirmed a heterogeneous mass filling the stomach with extension into the third portion of the duodenum (Figure A). Upon further questioning, the patient reported pulling out and eating her hair since the age of 12 when her parents divorced. Her hair is naturally very short and for the past 3 years she has been wearing synthetic hair extensions that she continued to eat. An upper endoscopy showed the presence of a large gastroduodenal trichobezoar occupying nearly the entire gastric lumen and extending past the second portion of the duodenum (Figure B). Endoscopic retrieval of the trichobezoar appeared unlikely to be successful and was not attempted. She subsequently underwent surgical removal of the trichobezoar through a 10-cm anterior gastrotomy. The trichobezoar was very firm, measured 13 13 9 cm, and was removed en bloc (Figure C). The patient had a normal postoperative recovery. Psychiatry diagnosed her with trichotillomania and recommended cognitive behavioral therapy. For 2 years after her surgery, she has refrained from further trichophagia despite continuing to wear hair extensions.

Safety of Deep Enteroscopy and Capsule Endoscopy in LVAD Patients: Case Report and Literature Review

Patients with a left ventricular assist device (LVAD) have increased risk of gastrointestinal (GI) bleeding. They are prone to develop angiodysplasia of the small intestine, and have a higher risk of bleeding as these patients are all required to be on permanent therapeutic anticoagulation. Here we report a case of a critically ill 55-year-old male on pressors and inotropes with an LVAD, who successfully underwent an antegrade double balloon enteroscopy (DBE).

Malignant cell contamination may lead to false-positive findings at endosonographic fine needle aspiration for tumor staging

BACKGROUND AND STUDY AIMS Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of lymph nodes is used for staging of gastrointestinal malignancies. False-positive rates of 5 % - 7 % are not well understood. Elements of EUS examinations that contribute to false-positive cytological findings were investigated. PATIENTS AND METHODS 13 patients undergoing EUS staging of gastrointestinal luminal malignancy were consecutively enrolled together with 3 patients with extraluminal tumors (pancreas, lung) defined as controls. After EUS, cellular debris and fluid were collected from the FNA needle catheter, instrument channel, and endoscope tip for cytologic and histologic investigation. RESULTS 6 of 13 patients (46 %) had malignant cells contaminating the FNA needle catheter, instrument channel, or endoscope tip. Malignant cells were present in the instrument channel in 5 cases (38 %), exterior tip of echoendoscope in 4 (31 %) and needle catheter in 2 (15 %). CONCLUSIONS Echoendoscopes used for FNA in patients with luminal tumors are at risk for malignant cell contamination of the instrument channel, FNA needle catheter, and echoendoscope tip. FNA needle contamination can contribute to false-positive findings.

Hypercalcemic Pancreatitis Triggered by Pregnancy With a CYP24A1 Mutation.

To the Editor: W e report the first case of hypercalcemic pancreatitis as a result of a CYP24A1 mutation. In 2011, loss-of-function mutations in the CYP24A1 gene were discovered to be a cause of idiopathic infantile hypercalcemia (Online Mendelian Inheritance in Man No.143880). The CYP24A1 gene encodes 25-hydroxyvitamin D 24hydroxylase, which is a key enzyme in the degradation of 1,25 dihydroxyvitamin D. Patients with loss-of-function mutations in CYP24A1 can develop hypercalcemia due to high levels of 1,25 dihydroxyvitamin D.

Lumen-apposing metal stent for gastric stricture after sleeve gastrectomy

Sleeve gastrectomy is a commonly performed bariatric procedure that is complicated by stricture formation in approximately 0.5% of cases. Gastric sleeve surgery adverse events, which can result in strictures and leaks, are increasingly managed through a minimally invasive endoscopic approach. Surgical revision of sleeve gastrectomy is associated with significant morbidity even when performed laparoscopically. Therefore, endoscopic management is the preferred option. However, the usual endoscopic management of strictures with balloon dilation and covered esophageal stents is not always successful and may require a repeated operation. We present a new endoscopic option for the management of gastric sleeve strictures refractory to usual endoscopic management.