Cytotoxic T-lymphocyte-associated antigen 4 antibody-induced colitis and its management with infliximab.

Anti-CTLA-4 antibodies are human monoclonal antibodies previously studied in the treatment of metastatic melanoma (MM). CTLA-4 is an inhibitory receptor on cytotoxic T cells, blockade of which will activate T cells allowing them to attack malignant cells. Normal host cells may also be affected, and immune-mediated enterocolitis can occur. This is a prospective observational study on the use of corticosteroids and infliximab in the treatment of patients with immune-mediated colitis secondary to anti-CTLA-4 antibody treatment of MM. Five patients presented with colitis after medication administration. Patients were treated with high-dose corticosteroids for 1 week, but diarrhea did not completely abate in any of them. They were then treated successfully with infliximab. One patient had recurrence of symptoms and responded to repeat treatment with infliximab. Patients who develop immune-mediated colitis after administration of anti-CTLA-4 antibodies have previously been reported to respond to corticosteroids, but in our study, all required treatment with infliximab.

Acute pancreatitis secondary to pancreatic carcinoma. Study Group Participants.

Acute pancreatitis (AP) has been recognized as a presentation of patients with pancreatic carcinoma (PC). However, the natural history of patients with PC who present with AP as the first manifestation is largely unknown. The aim of this study was to determine the time between the presentation of AP and diagnosis of PC and what factors should alert the clinician to suspect underlying PC in patients with AP. Nineteen physicians completed the survey forms that encompassed 45 patients with a diagnosis of AP preceding a diagnosis of PC. Information included the patient's age, gender, race, conditions that could account for the AP, criteria for diagnosis of AP, severity of AP, criteria for diagnosis of PC, time between the diagnosis of AP and PC, pathology of the carcinoma, extension of the disease, treatment of PC, and survival after the diagnosis of PC. The study population consisted of 45 patients, 27 (60%) men and 18 (40%) women whose average age was 58 years (range, 32-89). Thirty-eight patients were Caucasian, five were black, one was Japanese, and one Arabian. The number of AP episodes before PC diagnosis ranged between one and 15 (mean + 2 SD). AP was mild in 40 (89%) and severe in five (11%). The time between the onset of AP and the diagnosis of PC averaged 34 weeks (range, 1-52). Symptoms on presentation of AP included abdominal pain 45 (100%), weight loss 15 (33%), and jaundice 3 (7%). CA 19-9 was available in 13 patients, eight of whom had levels >100 at the time AP was diagnosed. Abnormal imaging suggestive of PC was detected by ultrasonography in 17 patients, by computed tomography in 30, endoscopic retrograde cholangiopancreatography in 20, and endoscopic ultrasonography in three. Tissue diagnosis was obtained in 43 of 45 (96%) patients; by surgery in 25 patients, needle aspiration in 14, laparoscopy in one, autopsy in two, and lymph node in one. Pathology revealed adenocarcinoma in 37 patients, squamous cell carcinoma in two, undifferentiated carcinoma in two, islet cell in one, and cystadenocarcinoma in one. Surgical findings in 26 patients included 19 with a nonresectable lesion or metastasis and seven patients with resectable lesion for cure. Thirteen patients (28%) were alive 1 year after the diagnosis of PC. The patients had a mean of two (range, one to 15) episodes of AP before the diagnosis of PC, and this was associated with a delay of 34 weeks from AP to diagnosis of PC. Patients with PC who presented with AP were generally older than 50 years of age and the severity of the pancreatitis was mild. The survival rate of patients with PC who presented initially with AP was >25% at 1 year compared with 20% 1 year overall survival of patients with PC. AP seems to be an early presentation of PC and should be sought in patients with idiopathic pancreatitis.

Diagnostic and therapeutic options in obscure gastrointestinal blood loss.

Obscure gastrointestinal bleeding is defined as an intermittent or chronic loss of blood manifested by iron deficiency anemia or overt bleeding the source of which has not been identified in upper endoscopy, colonoscopy, and barium studies. The diagnostic work-up includes repeat upper endoscopy and colonoscopy, push enteroscopy, radionuclide bleeding scan, angiography, and exploratory laparotomy with intra-operative enteroscopy. Recent publications regarding these and new diagnostic modalities, as well as advances in therapy, including combination hormonal therapy, are reviewed.

Diagnostic and therapeutic approach to pancreatic cancer.

Adenocarcinoma of the pancreas ranks fourth as a cause of cancer death in adults in the United States and is the second most common cause of cancer deaths of all GI-related carcinomas. It usually presents late in its course. The clinical features are discussed, with emphasis on those that allow early detection of the disease, as well as a review of diagnostic methods and pre- and perioperative staging, which will allow the appropriate application of surgical and palliative therapeutic modalities. Despite the significant progress that has been made, further research studies are needed to advance our therapeutic approach to this aggressive cancer.

Just a little heartburn?

Lagergren et al. performed a population-based, case-control study to investigate the possible association between gastroesophageal reflux (GER) and adenocarcinoma of the esophagus and gastric cardia. They demonstrated an odds ratio of 7.7 for esophageal adenocarcinoma in patients with GER symptoms. The frequency, severity, and duration of symptoms correlated with an increased risk of esophageal adenocarcinoma. A weaker association was noted for GER and adenocarcinoma of the gastric cardia. No association surfaced between GER and squamous cell carcinoma of the esophagus.

Comparison of the diameter consistency and dilating force of the controlled radial expansion balloon catheter to the conventional balloon dilators.

OBJECTIVES: Balloon dilation of a luminal narrowing is classically performed with a single-diameter balloon. A new multidiameter balloon that allows three progressively larger, controlled radial expansion diameters of a single-balloon catheter (controlled radial expansion, CRE) has been developed. The purpose of this study was to test the diameter consistency and dilating force at increasing pressure of the CRE balloon-dilating catheter and to compare these features with the conventional balloon-dilating catheters. METHODS: The CRE balloon catheter was compared with the Achiever, Eliminator, and Max Force using in vitro testing to determine their dilating diameters and dilating forces. RESULTS AND CONCLUSIONS: This in vitro study has shown that the new CRE balloon catheter with increasing diameter delivers consistently reproducible and progressively greater dilating force. This dilating force of the CRE balloon catheter at its third and maximum diameter inflation was similar to that of the Max Force TTS and significantly greater than that of the conventional balloon dilators, Eliminator and Achiever.